Provider Demographics
NPI:1528029162
Name:RAJ, MADANKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MADANKUMAR
Middle Name:
Last Name:RAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MADAN
Other - Middle Name:K
Other - Last Name:RAJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 HOLIDAY POND RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1154
Mailing Address - Country:US
Mailing Address - Phone:516-478-0010
Mailing Address - Fax:516-482-0143
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 113
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-441-5739
Practice Address - Fax:516-441-5743
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2314932081P2900X, 208VP0014X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI35615Medicare PIN