Provider Demographics
NPI:1962484139
Name:DHARAMRAJ, KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:DHARAMRAJ
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 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:1254 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1343
Practice Address - Country:US
Practice Address - Phone:810-664-4531
Practice Address - Fax:810-667-7337
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI201569OtherMCLAREN HEALTH PLAN
MIC5691OtherMCARE
MI3640942004OtherCIGNA
MIA78935OtherHEALTH NET FED SERVICES
MI0104255401OtherHEALTHPLUS
MI3504422641OtherBLUE CROSS BLUE SHIELD
MI201569OtherHEALTH ADVANTAGE
MI4568147Medicaid
MI5604138OtherAETNA
MIA78935OtherHAP
MI4494689Medicaid
MIA78935OtherHEALTH NET FED SERVICES
MI5604138OtherAETNA