Provider Demographics
NPI:1952667974
Name:PENUMETSA, RAJ
Entity Type:Individual
Prefix:
First Name:RAJ
Middle Name:
Last Name:PENUMETSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 PICKLE RD APT 11
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3935
Mailing Address - Country:US
Mailing Address - Phone:567-277-0342
Mailing Address - Fax:
Practice Address - Street 1:2750 PICKLE RD APT 11
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3935
Practice Address - Country:US
Practice Address - Phone:567-277-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU9769207Q00000X
OH35.126661208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine