Basic Information
| Provider Information | |||||||||
| NPI: | 1932413168 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DHARMARAJ | ||||||||
| FirstName: | RAJMOHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS - GASTROENTEROLOGY | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725551 | ||||||||
| FaxNumber: | 5052726845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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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 | 208000000X | 4301096421 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 60082 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | MD2015-0835 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1932413168 | 05 | WI | MEDICAID |