Provider Demographics
NPI:1912108820
Name:MANAM, RAJESH (MD)
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:MANAM
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 1:1703 S MERIDIAN STE 305
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1703 S MERIDIAN STE 305
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7590
Practice Address - Country:US
Practice Address - Phone:253-272-8512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047698207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00047698OtherWA LICENSE
WA8483893Medicaid
WAG8851595Medicare PIN
WAG8851597Medicare PIN
WAG8851596Medicare PIN
WAP00619718Medicare PIN
WA001045700Medicare PIN
WA000188100Medicare PIN
WAG8851594Medicare PIN
WA8867062Medicare PIN
WA8867063Medicare PIN
WAG8880511Medicare PIN
WA8851594Medicare PIN