Provider Demographics
NPI:1700847142
Name:JINNA, RAJENDER REDDY (MD)
Entity Type:Individual
Prefix:
First Name:RAJENDER
Middle Name:REDDY
Last Name:JINNA
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 1:380 NASSAU RD
Mailing Address - Street 2:LONG ISLAND FQHC, INC.
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-571-8600
Mailing Address - Fax:
Practice Address - Street 1:682 UNION AVE
Practice Address - Street 2:LONG ISLAND FQHC, INC.
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3552
Practice Address - Country:US
Practice Address - Phone:516-571-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186081208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01340096Medicaid
NY66K801Medicare PIN
NYF31126Medicare UPIN