Provider Demographics
NPI:1659451268
Name:RAJARAM, CHALAT (MD)
Entity Type:Individual
Prefix:
First Name:CHALAT
Middle Name:
Last Name:RAJARAM
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 1:14901 FOXCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6726
Mailing Address - Country:US
Mailing Address - Phone:714-547-3346
Mailing Address - Fax:714-547-3252
Practice Address - Street 1:14901 FOXCROFT RD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6726
Practice Address - Country:US
Practice Address - Phone:714-547-3346
Practice Address - Fax:714-547-3252
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A453710Medicaid
CAA45371Medicare PIN
CA00A453710Medicaid