Provider Demographics
NPI:1134336563
Name:KADAM, RAJESH SHIVAJI (MD)
Entity type:Individual
Prefix:DR
First Name:RAJESH
Middle Name:SHIVAJI
Last Name:KADAM
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 1:403 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6034
Mailing Address - Country:US
Mailing Address - Phone:423-431-7047
Mailing Address - Fax:423-979-0569
Practice Address - Street 1:403 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6034
Practice Address - Country:US
Practice Address - Phone:423-431-7047
Practice Address - Fax:423-979-0569
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN517207RA0000X, 2084P0800X
TN425762084P0800X
VA01012415382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1504642Medicaid
VA1134336563Medicaid
TN3001511Medicaid
VA1134336563Medicaid
TN1504642Medicaid
VAVVD917AMedicare PIN
TN30015111Medicare PIN