Provider Demographics
NPI:1841330552
Name:RAJ, BALEBAIL ASHOK (MD)
Entity type:Individual
Prefix:
First Name:BALEBAIL
Middle Name:ASHOK
Last Name:RAJ
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 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4808
Practice Address - Country:US
Practice Address - Phone:813-866-1611
Practice Address - Fax:813-866-1612
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 313002084P0805X
FLME313002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038863700Medicaid
FL30102WMedicare PIN
FLD-85498Medicare UPIN
FL038863700Medicaid