Provider Demographics
NPI:1740378629
Name:MARIWALLA, RAJESH (MD)
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:MARIWALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 MONTAUK HWY
Mailing Address - Street 2:SUITE #4
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795
Mailing Address - Country:US
Mailing Address - Phone:631-422-9600
Mailing Address - Fax:631-422-9697
Practice Address - Street 1:1175 MONTAUK HWY
Practice Address - Street 2:SUITE #4
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-422-9600
Practice Address - Fax:631-422-9697
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153786208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics