Basic Information
| Provider Information | |||||||||
| NPI: | 1184733156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAJ | ||||||||
| FirstName: | SHEKHAR | ||||||||
| MiddleName: | SIDDAPPA | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SIDDAPPA | ||||||||
| OtherFirstName: | RAJASHEKHAR | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 660645 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752660645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616945445 | ||||||||
| FaxNumber: | 3616945449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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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 | 2080P0203X | 01053263 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 207LC0200X | 01053263 | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 208000000X | Q7598 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036103896 | 05 | IL | MEDICAID | 200338070 | 05 | IN | MEDICAID | 1810967 | 05 | LA | MEDICAID | P01824553 | 01 | IN | RR MEDICARE | OTHER | 7100316660 | 05 | KY | MEDICAID | 022990723A | 05 | GA | MEDICAID | 1021332 | 05 | VT | MEDICAID |