Provider Demographics
NPI:1912372871
Name:RAJ, RAKSHA
Entity Type:Individual
Prefix:
First Name:RAKSHA
Middle Name:
Last Name:RAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4639
Mailing Address - Country:US
Mailing Address - Phone:718-513-6911
Mailing Address - Fax:718-513-6912
Practice Address - Street 1:462 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-689-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00663100152WC0802X
NYTUV008260-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04359624Medicaid