Provider Demographics
NPI:1669676326
Name:SUBRAMANIAN, SAKTHIRAJ (MD)
Entity Type:Individual
Prefix:
First Name:SAKTHIRAJ
Middle Name:
Last Name:SUBRAMANIAN
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 1:5700 E INTERSTATE 20 SERVICE RD S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76008-5115
Mailing Address - Country:US
Mailing Address - Phone:781-748-9730
Mailing Address - Fax:181-748-9730
Practice Address - Street 1:5700 E INTERSTATE 20 SERVICE RD S
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76008-5115
Practice Address - Country:US
Practice Address - Phone:817-489-7300
Practice Address - Fax:181-748-9730
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2747184Medicaid
OHP00462034OtherRR MEDICARE
OH4217361Medicare PIN