Provider Demographics
NPI:1427095918
Name:RAJARETHINAM, RAJAPRABHAKARAN (MD)
Entity type:Individual
Prefix:
First Name:RAJAPRABHAKARAN
Middle Name:
Last Name:RAJARETHINAM
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 1:3001 PLYMOUTH RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-3205
Mailing Address - Country:US
Mailing Address - Phone:734-846-2898
Mailing Address - Fax:
Practice Address - Street 1:3001 PLYMOUTH RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-3205
Practice Address - Country:US
Practice Address - Phone:734-846-2898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010640332084P0800X
MA2502292084P0800X
MI6301013432101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4902521Medicaid
MI0P30630251OtherMEDICARE NUMBER
MIG59463Medicare UPIN