Provider Demographics
NPI:1962560953
Name:ANANDARAJAH, RAJAMANIKKAM (MD)
Entity type:Individual
Prefix:DR
First Name:RAJAMANIKKAM
Middle Name:
Last Name:ANANDARAJAH
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-3500
Practice Address - Fax:417-820-7852
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110190622OtherRAILROAD MEDICARE
MO203999701Medicaid
431560263OtherTRICARE
110190622OtherRAILROAD MEDICARE
MO153013268Medicare PIN