Provider Demographics
NPI:1134174691
Name:RATHAKRISHNAN, RANGA (MD)
Entity type:Individual
Prefix:
First Name:RANGA
Middle Name:
Last Name:RATHAKRISHNAN
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 1:1617 HULL CT
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8583
Mailing Address - Country:US
Mailing Address - Phone:561-293-1585
Mailing Address - Fax:
Practice Address - Street 1:7305 N MILITARY TRL
Practice Address - Street 2:MEDICINE
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-293-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-02-29
Deactivation Date:2006-06-16
Deactivation Code:
Reactivation Date:2006-06-26
Provider Licenses
StateLicense IDTaxonomies
FLME89030207R00000X, 208M00000X
OK23240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME89030OtherLICENSE
VAD000Medicare UPIN