1528012325 NPI number — DR. RAO R KOSARAJU MD

Table of content: DR. RAO R KOSARAJU MD (NPI 1528012325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528012325 NPI number — DR. RAO R KOSARAJU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSARAJU
Provider First Name:
RAO
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAO
Provider Other First Name:
KOSARAJU
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528012325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1999 MOWRY AVE
Provider Second Line Business Mailing Address:
SUITE L
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94538-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-373-3000
Provider Business Mailing Address Fax Number:
510-744-9959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1999 MOWRY AVE
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94538-1731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-373-3000
Provider Business Practice Location Address Fax Number:
510-744-9959
Provider Enumeration Date:
05/19/2006

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: 207KA0200X , with the licence number:  43123 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207KA0200X , with the licence number: A30703 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0043790 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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