Basic Information
| Provider Information | |||||||||
| NPI: | 1184666539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAJU | ||||||||
| FirstName: | PENUMETSA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 KIMBALL AVE | ||||||||
| Address2: | LL14 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192721590 | ||||||||
| FaxNumber: | 3192721535 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192728922 | ||||||||
| FaxNumber: | 3192728929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 18458 | IA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3179598 | 05 | IA | MEDICAID |