Provider Demographics
NPI:1790863801
Name:MULLANGI, RAJAN S (MD)
Entity type:Individual
Prefix:
First Name:RAJAN
Middle Name:S
Last Name:MULLANGI
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-833-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL223980Medicare PIN