Provider Demographics
NPI:1881638856
Name:RAJU, TIRUPATI GANAPATI (MD)
Entity Type:Individual
Prefix:
First Name:TIRUPATI
Middle Name:GANAPATI
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 1:100 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1394
Mailing Address - Country:US
Mailing Address - Phone:718-967-4692
Mailing Address - Fax:718-836-1087
Practice Address - Street 1:7104 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1106
Practice Address - Country:US
Practice Address - Phone:718-748-1200
Practice Address - Fax:718-836-1087
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209245207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02093956Medicaid
NYG80678Medicare UPIN