Provider Demographics
NPI:1053570085
Name:RAJU, SRIRANGARAJAN (MD)
Entity type:Individual
Prefix:
First Name:SRIRANGARAJAN
Middle Name:
Last Name:RAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8759
Mailing Address - Country:US
Mailing Address - Phone:928-226-6439
Mailing Address - Fax:928-226-6411
Practice Address - Street 1:1759 E VILLA DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4681
Practice Address - Country:US
Practice Address - Phone:289-235-8835
Practice Address - Fax:289-226-6411
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8258208M00000X
AZ55671207RS0012X
ARE-8258207RS0012X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053570085Medicaid
AZ47064Medicaid
AZZ222252OtherMEDICARE PIN
IL1053570085Medicaid