Provider Demographics
NPI:1568683316
Name:RAJU, SUBBA (MBBS)
Entity Type:Individual
Prefix:
First Name:SUBBA
Middle Name:
Last Name:RAJU
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 GRAYDON AVE
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DRIVE
Practice Address - Street 2:SUITE 350
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305
Practice Address - Country:US
Practice Address - Phone:952-932-9012
Practice Address - Fax:952-932-7122
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28038207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology