Provider Demographics
NPI:1912974221
Name:RAO, KODEM S (MD)
Entity Type:Individual
Prefix:DR
First Name:KODEM
Middle Name:S
Last Name:RAO
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 479
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-0479
Mailing Address - Country:US
Mailing Address - Phone:937-440-7497
Mailing Address - Fax:937-339-5569
Practice Address - Street 1:31 S STANFIELD RD
Practice Address - Street 2:SUITE 206
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2374
Practice Address - Country:US
Practice Address - Phone:937-335-6463
Practice Address - Fax:937-440-7230
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044565208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0434113Medicaid
OH0473876Medicare ID - Type Unspecified
OH0434113Medicaid