Provider Demographics
NPI:1629037460
Name:RAJU, KOCHUVILA K (MD)
Entity Type:Individual
Prefix:DR
First Name:KOCHUVILA
Middle Name:K
Last Name:RAJU
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 1:1 EDGEWATER ST
Mailing Address - Street 2:6TH FL. PAYER RELATIONS
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:375 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3932
Practice Address - Country:US
Practice Address - Phone:718-226-6902
Practice Address - Fax:718-967-2165
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00094368OtherRAILROAD MEDICARE
NY00965655Medicaid
NYA64631Medicare UPIN
NY88D07EL471Medicare PIN
NY88D071Medicare PIN