Provider Demographics
NPI:1710922190
Name:RAJAGOPAL, KRISHNAN R (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNAN
Middle Name:R
Last Name:RAJAGOPAL
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 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-224-1044
Mailing Address - Fax:574-224-1103
Practice Address - Street 1:1430 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-8931
Practice Address - Country:US
Practice Address - Phone:574-223-9525
Practice Address - Fax:574-223-9521
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427793207RP1001X
IN01064184A207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200484030AMedicaid
PA101489839Medicaid
IN200877540Medicaid
PA101489839Medicaid
097131Medicare ID - Type Unspecified
IN217670DMedicare PIN
IN200877540Medicaid
INM400075982Medicare PIN