Provider Demographics
NPI:1700859394
Name:RAJU, NIRANJANA (MD)
Entity Type:Individual
Prefix:
First Name:NIRANJANA
Middle Name:
Last Name:RAJU
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:573-883-4477
Mailing Address - Fax:
Practice Address - Street 1:930 PARK DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1539
Practice Address - Country:US
Practice Address - Phone:573-883-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOR6A98207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO193294OtherHEALTHLINK
MO46047OtherHEALTHCARE USA
MO999554OtherCOMMUNITY CARE PLUS
MO060023232OtherRAILROAD MEDICARE
MO201290004Medicaid
MOA11284OtherMERCY HEALTH
MO0450220OtherUHC
MO23094OtherBLUE CHOICE
MO36162OtherBCBS
MO4574132OtherAETNA
MO46047OtherGHP
MO46047OtherGHP
A11284Medicare UPIN