Basic Information
| Provider Information | |||||||||
| NPI: | 1184861502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEHANNA | ||||||||
| FirstName: | RAJA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | SUITE 1014 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257080 | ||||||||
| FaxNumber: | 7135122239 | ||||||||
| Practice Location | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | SUITE 1014 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257080 | ||||||||
| FaxNumber: | 7135122239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | P7953 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 315286YKY3 | 01 | MEDICARE | OTHER | 326051502 | 01 | CSHCN | OTHER | P01428484 | 01 | RR MEDICARE | OTHER | 326051501 | 05 | TX | MEDICAID | 8DY143 | 01 | BCBS | OTHER |