Provider Demographics
NPI:1275534828
Name:RAO, RAMACHANDRA N (MD)
Entity Type:Individual
Prefix:
First Name:RAMACHANDRA
Middle Name:N
Last Name:RAO
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 1:18275 N 59TH AVE
Mailing Address - Street 2:142
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1253
Mailing Address - Country:US
Mailing Address - Phone:602-564-0110
Mailing Address - Fax:602-564-0111
Practice Address - Street 1:18275 N 59TH AVE
Practice Address - Street 2:STE 142
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1260
Practice Address - Country:US
Practice Address - Phone:602-564-0110
Practice Address - Fax:602-564-0111
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2012-07-23
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
AZ25615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ428088Medicaid
AZ428088Medicaid
AZG61124Medicare UPIN