Provider Demographics
NPI:1841283439
Name:FATTALEH, RAJA (MD)
Entity type:Individual
Prefix:
First Name:RAJA
Middle Name:
Last Name:FATTALEH
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:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-0333
Mailing Address - Country:US
Mailing Address - Phone:860-928-1111
Mailing Address - Fax:860-963-7756
Practice Address - Street 1:353 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1835
Practice Address - Country:US
Practice Address - Phone:860-928-1111
Practice Address - Fax:860-963-7756
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001381889Medicaid
080001690Medicare ID - Type Unspecified
CT001381889Medicaid