Provider Demographics
NPI:1699898809
Name:RAJU, VIDYA (MD)
Entity type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3210
Mailing Address - Country:US
Mailing Address - Phone:781-233-1450
Mailing Address - Fax:
Practice Address - Street 1:1069 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3210
Practice Address - Country:US
Practice Address - Phone:781-233-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188576208000000X
MA244048208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics