Basic Information
| Provider Information | |||||||||
| NPI: | 1215019328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDIPOTI | ||||||||
| FirstName: | RAJA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26067 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240400 | ||||||||
| FaxNumber: | 2396240464 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 9TH ST N STE 201 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341028143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392612000 | ||||||||
| FaxNumber: | 2392612266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036-082727 | IL | N | Other Service Providers | Specialist | 207RC0000X | 036082727 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | ME143903 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036082727 | 05 | IL | MEDICAID | 060067999 | 01 | IL | RAILROAD | OTHER |