1326326968 NPI number — DR. SHINE KOCHUKUNJU RAJU M.B.B.S.

Table of content: DR. SHINE KOCHUKUNJU RAJU M.B.B.S. (NPI 1326326968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326326968 NPI number — DR. SHINE KOCHUKUNJU RAJU M.B.B.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCHUKUNJU RAJU
Provider First Name:
SHINE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.B.B.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326326968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
83 LEAFWOOD LN
Provider Second Line Business Mailing Address:
APT 220
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-6250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-943-2400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UCONN HEALTH CTR
Provider Second Line Business Practice Location Address:
263 FARMINGTON AVE
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-943-2400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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