Provider Demographics
NPI:1134237050
Name:MANAM, RAJENDRA KUMAR (MD)
Entity type:Individual
Prefix:
First Name:RAJENDRA
Middle Name:KUMAR
Last Name:MANAM
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 1:22301 FOSTER WINTER DR
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3707
Mailing Address - Country:US
Mailing Address - Phone:248-552-0620
Mailing Address - Fax:248-552-0286
Practice Address - Street 1:22301 FOSTER WINTER DR
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3707
Practice Address - Country:US
Practice Address - Phone:248-552-0620
Practice Address - Fax:248-552-0286
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067586207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H11319Medicare UPIN