Provider Demographics
NPI:1730290321
Name:RAJA, MANIKANDA G (MD)
Entity type:Individual
Prefix:DR
First Name:MANIKANDA
Middle Name:G
Last Name:RAJA
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 1:1701 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4632
Mailing Address - Country:US
Mailing Address - Phone:951-658-4486
Mailing Address - Fax:951-925-1026
Practice Address - Street 1:1701 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4632
Practice Address - Country:US
Practice Address - Phone:951-658-4486
Practice Address - Fax:951-925-1026
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53777207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A537770Medicaid
CAG52721Medicare UPIN
CA00A537770Medicare ID - Type Unspecified