Provider Demographics
NPI:1740251404
Name:RAJAGOPAL, ADIKKAN OANTHAN (MD)
Entity type:Individual
Prefix:
First Name:ADIKKAN
Middle Name:OANTHAN
Last Name:RAJAGOPAL
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 1:3949 EVANS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9335
Mailing Address - Country:US
Mailing Address - Phone:239-939-2622
Mailing Address - Fax:239-939-0151
Practice Address - Street 1:3949 EVANS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9335
Practice Address - Country:US
Practice Address - Phone:239-939-2622
Practice Address - Fax:239-939-0151
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036289207L00000X
FLME29883207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278064000Medicaid
FLAD661ZOtherGTBA MEDICARE REASSIGN
FL96524OtherBCBS
B43873OtherUPIN
FL5829419OtherAETNA
MI050G310140OtherBCBS OF MI
P86627Medicare UPIN
FLAD661ZMedicare PIN
FL278064000Medicaid