Provider Demographics
NPI:1801281415
Name:SUBBARAYAN, RAHUL SRIDHAR (MD)
Entity type:Individual
Prefix:
First Name:RAHUL
Middle Name:SRIDHAR
Last Name:SUBBARAYAN
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 1:119 E BELL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4993
Mailing Address - Country:US
Mailing Address - Phone:614-313-3149
Mailing Address - Fax:
Practice Address - Street 1:444 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5715
Practice Address - Country:US
Practice Address - Phone:920-969-1768
Practice Address - Fax:920-267-5222
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73398-20207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty