Provider Demographics
NPI:1578659793
Name:RAJESWAREN, RAJ (MD)
Entity Type:Individual
Prefix:
First Name:RAJ
Middle Name:
Last Name:RAJESWAREN
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:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8630
Mailing Address - Fax:
Practice Address - Street 1:2300 N VERMILION AVENUE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1735
Practice Address - Country:US
Practice Address - Phone:217-431-7830
Practice Address - Fax:217-431-7756
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360625172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062517Medicaid
ILC44994Medicare UPIN
ILF400104872Medicare PIN
673130Medicare ID - Type Unspecified