Provider Demographics
NPI:1689631442
Name:RAJA, PREMKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PREMKUMAR
Middle Name:
Last Name:RAJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 896158
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6158
Mailing Address - Country:US
Mailing Address - Phone:304-388-1790
Mailing Address - Fax:304-388-1795
Practice Address - Street 1:3415 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1334
Practice Address - Country:US
Practice Address - Phone:304-388-1790
Practice Address - Fax:304-388-1795
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV213362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2006367000Medicaid
WV4119201Medicare PIN
WVH96298Medicare UPIN