Basic Information
| Provider Information | |||||||||
| NPI: | 1992010433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAJAN | ||||||||
| FirstName: | DERRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1406 COLLEGE DR 1 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755033580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036147693 | ||||||||
| FaxNumber: | 9036145343 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162558400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | AC4187868124 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Q2833 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.