Provider Demographics
NPI:1770513137
Name:RUDRARAJU, VENKAT CHINNA (MD)
Entity type:Individual
Prefix:DR
First Name:VENKAT
Middle Name:CHINNA
Last Name:RUDRARAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VENKATESWARLU
Other - Middle Name:CHINNA
Other - Last Name:RUDRARAJU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:840 OAKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2319
Mailing Address - Country:US
Mailing Address - Phone:313-359-7600
Mailing Address - Fax:313-359-7678
Practice Address - Street 1:840 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2319
Practice Address - Country:US
Practice Address - Phone:313-359-7600
Practice Address - Fax:313-359-7678
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010679272085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406149Medicaid
MI300132548OtherRAILROAD MEDICARE