Basic Information
| Provider Information | |||||||||
| NPI: | 1043508070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHENDRARAJAH | ||||||||
| FirstName: | SULAGSHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 WITTENBURGH APT 2408 | ||||||||
| Address2: | |||||||||
| City: | KYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786402692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193831834 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895790 | ||||||||
| FaxNumber: | 5417895711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R-9294 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | T2672 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD170301 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.