Provider Demographics
NPI:1689900698
Name:RAJU, ROY PHILIP (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:PHILIP
Last Name:RAJU
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 TENAFLY DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3641
Mailing Address - Country:US
Mailing Address - Phone:516-467-6455
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQK45267WMedicaid