Basic Information
| Provider Information | |||||||||
| NPI: | 1558362202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUJJA | ||||||||
| FirstName: | RAJITHA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419430 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022419430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019678221 | ||||||||
| FaxNumber: | 2014832242 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 CLAREMONT AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070422833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733384900 | ||||||||
| FaxNumber: | 9733384420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA07684900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0033243 | 05 | NJ | MEDICAID |