Provider Demographics
NPI:1417962291
Name:JOTHIKUMAR, THANKARAJAM (MD)
Entity Type:Individual
Prefix:DR
First Name:THANKARAJAM
Middle Name:
Last Name:JOTHIKUMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 N CHINA LAKE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2667
Mailing Address - Country:US
Mailing Address - Phone:760-446-1691
Mailing Address - Fax:760-446-1642
Practice Address - Street 1:1535 N CHINA LAKE BLVD STE A
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2667
Practice Address - Country:US
Practice Address - Phone:760-446-1691
Practice Address - Fax:760-446-1642
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA31143OtherCA LICENSE
CA00A311430Medicare PIN
CAA87514Medicare UPIN