Provider Demographics
NPI:1508556333
Name:RAJASRI, MONISSA (MD)
Entity Type:Individual
Prefix:MS
First Name:MONISSA
Middle Name:
Last Name:RAJASRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S. HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-8908
Mailing Address - Fax:815-285-8926
Practice Address - Street 1:102 S. HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-8908
Practice Address - Fax:815-285-8926
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125082430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty