Provider Demographics
NPI:1861460214
Name:KOLISETTI, RAJA (MD)
Entity Type:Individual
Prefix:
First Name:RAJA
Middle Name:
Last Name:KOLISETTI
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 333
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14021-0333
Mailing Address - Country:US
Mailing Address - Phone:585-591-6000
Mailing Address - Fax:585-591-6962
Practice Address - Street 1:107 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:NY
Practice Address - Zip Code:14011-1149
Practice Address - Country:US
Practice Address - Phone:585-591-6000
Practice Address - Fax:585-591-6962
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0160325Medicaid
NYBA0156Medicare PIN
NY0160325Medicaid