Basic Information
| Provider Information | |||||||||
| NPI: | 1043548019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | V. RAJA CHANDRA, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 519 8TH ST | ||||||||
| Address2: | PO BOX 1768 | ||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823015460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073242294 | ||||||||
| FaxNumber: | 3073281964 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 8TH ST | ||||||||
| Address2: | |||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823015460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073242294 | ||||||||
| FaxNumber: | 3073281964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2009 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHANDRASEKARAN | ||||||||
| AuthorizedOfficialFirstName: | VENKATAPERUMAL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3073242294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 2812A | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 760011087 | 01 | WY | RAILROAD MEDICARE | OTHER | 00072001 | 01 | WY | BCBS | OTHER | 106489400 | 05 | WY | MEDICAID |