Provider Demographics
NPI:1154542298
Name:SKANTHARAJA, RAJARATNAM (MD)
Entity type:Individual
Prefix:
First Name:RAJARATNAM
Middle Name:
Last Name:SKANTHARAJA
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:1501 OAKDALE RD
Practice Address - Street 2:SUITE 218
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3381
Practice Address - Country:US
Practice Address - Phone:209-572-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065489208G00000X
CAC54594208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)