Provider Demographics
NPI:1497839328
Name:BOTHRA, RAJENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJENDRA
Middle Name:
Last Name:BOTHRA
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 1:27423 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2867
Mailing Address - Country:US
Mailing Address - Phone:586-757-4000
Mailing Address - Fax:586-755-9880
Practice Address - Street 1:27423 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2867
Practice Address - Country:US
Practice Address - Phone:586-757-4000
Practice Address - Fax:586-755-9880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB033013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist