Provider Demographics
NPI:1104994227
Name:RAJCOOMAR, BHAGWANDATT (MD)
Entity type:Individual
Prefix:DR
First Name:BHAGWANDATT
Middle Name:
Last Name:RAJCOOMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:RAJCOOMAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4765 S CONGRESS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4700
Mailing Address - Country:US
Mailing Address - Phone:561-965-5705
Mailing Address - Fax:561-964-1188
Practice Address - Street 1:4765 S CONGRESS AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4700
Practice Address - Country:US
Practice Address - Phone:561-965-5705
Practice Address - Fax:561-964-1188
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35579207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048779100Medicaid
FL47033Medicare ID - Type Unspecified