Provider Demographics
NPI:1356377915
Name:IMMARAJ, PREMSWARUP JOEL (MD)
Entity type:Individual
Prefix:
First Name:PREMSWARUP
Middle Name:JOEL
Last Name:IMMARAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IMMARAJU
Other - Middle Name:JOEL
Other - Last Name:PREMSWARUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5447 EMBERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4273
Mailing Address - Country:US
Mailing Address - Phone:832-264-4028
Mailing Address - Fax:
Practice Address - Street 1:110 MEMORIAL HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4940
Practice Address - Country:US
Practice Address - Phone:936-291-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4655207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168572909Medicaid
TX168572904Medicaid
TX168572903Medicaid
TX168572903Medicaid
TX8G9521Medicare PIN