Provider Demographics
NPI:1295755759
Name:GOVINDARAJAN, ILANGOVAN (MD, CMD)
Entity type:Individual
Prefix:
First Name:ILANGOVAN
Middle Name:
Last Name:GOVINDARAJAN
Suffix:
Gender:M
Credentials:MD, CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3548
Mailing Address - Country:US
Mailing Address - Phone:928-692-1900
Mailing Address - Fax:928-692-7334
Practice Address - Street 1:975 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3548
Practice Address - Country:US
Practice Address - Phone:928-692-1900
Practice Address - Fax:928-692-7334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ405036Medicaid
AZG61742Medicare UPIN
AZZ85116Medicare ID - Type Unspecified