Provider Demographics
NPI:1801955323
Name:RAJU, GOTTUMUKKALA S (MD)
Entity type:Individual
Prefix:
First Name:GOTTUMUKKALA
Middle Name:S
Last Name:RAJU
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 1:1515 HOLCOMBE BLVD UNIT 1466
Mailing Address - Street 2:THE UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4000
Mailing Address - Country:US
Mailing Address - Phone:713-794-5073
Mailing Address - Fax:713-745-5040
Practice Address - Street 1:1515 HOLCOMBE BLVD UNIT 1466
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4000
Practice Address - Country:US
Practice Address - Phone:713-794-5073
Practice Address - Fax:713-745-5040
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2576207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142193501Medicaid
TXG16685Medicare UPIN
TX142193501Medicaid