Basic Information
| Provider Information | |||||||||
| NPI: | 1285090019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAJITHA GUJJA MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 239 CLAREMONT AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070422833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733384900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 239 CLAREMONT AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070422833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733384900 | ||||||||
| FaxNumber: | 9733384420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2016 | ||||||||
| LastUpdateDate: | 01/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | GUJJA | ||||||||
| AuthorizedOfficialFirstName: | RAJITHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9733384900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA07684900 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0033243 | 05 | NJ | MEDICAID |