Provider Demographics
NPI:1467485953
Name:RAJENDRAN, PATTABHIRAMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATTABHIRAMAN
Middle Name:
Last Name:RAJENDRAN
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 1:1507 W REYNOLDS ST
Mailing Address - Street 2:STE B
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4702
Mailing Address - Country:US
Mailing Address - Phone:813-752-1053
Mailing Address - Fax:813-754-6739
Practice Address - Street 1:1507 W REYNOLDS ST
Practice Address - Street 2:STE B
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4702
Practice Address - Country:US
Practice Address - Phone:813-752-1053
Practice Address - Fax:813-754-6739
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044065174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL204777OtherAVMED
FL110046858OtherRAILROAD
FL069482700Medicaid
FL30704OtherBCBS
FL110046858OtherRAILROAD
FL069482700Medicaid