Provider Demographics
NPI:1366775199
Name:RAJENDRAN, RAJAVARMAN (PT)
Entity type:Individual
Prefix:MR
First Name:RAJAVARMAN
Middle Name:
Last Name:RAJENDRAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 BERGERON PLACE
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-558-0610
Mailing Address - Fax:
Practice Address - Street 1:2346 WISTERIA DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-8847
Practice Address - Country:US
Practice Address - Phone:404-889-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1177460225100000X
PT011513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021738201Medicaid
TX021738201Medicaid