Provider Demographics
NPI:1356417919
Name:RAJAMANICKAM, SURESH (MD)
Entity type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:RAJAMANICKAM
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 1:5929 BALCONES DR
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4280
Mailing Address - Country:US
Mailing Address - Phone:561-793-3363
Mailing Address - Fax:561-793-3365
Practice Address - Street 1:1395 S STATE ROAD 7
Practice Address - Street 2:SUITE350
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9325
Practice Address - Country:US
Practice Address - Phone:561-793-3363
Practice Address - Fax:561-793-3365
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9977174400000X
CODR.0065508174400000X, 207KA0200X
FL72337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264775300Medicaid
FL51698Medicare ID - Type Unspecified