Provider Demographics
NPI:1205939741
Name:RAJARAM, VENKATAKRISHNAN (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATAKRISHNAN
Middle Name:
Last Name:RAJARAM
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 1:1485 ROYALOAK TRAIL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906
Mailing Address - Country:US
Mailing Address - Phone:419-756-2310
Mailing Address - Fax:
Practice Address - Street 1:1456 PARK AVENUE WEST
Practice Address - Street 2:H-1
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906
Practice Address - Country:US
Practice Address - Phone:419-529-4602
Practice Address - Fax:419-529-4664
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH23160Medicare UPIN