Provider Demographics
NPI:1144284860
Name:TALLURI, RAJA S (MD)
Entity type:Individual
Prefix:
First Name:RAJA
Middle Name:S
Last Name:TALLURI
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:P.O. BOX 69
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090
Mailing Address - Country:US
Mailing Address - Phone:225-265-3061
Mailing Address - Fax:225-265-3062
Practice Address - Street 1:22080 LA HWY 20
Practice Address - Street 2:
Practice Address - City:VACHERIE
Practice Address - State:LA
Practice Address - Zip Code:70090
Practice Address - Country:US
Practice Address - Phone:225-265-3061
Practice Address - Fax:225-265-3062
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12874R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1549029Medicaid
LA5E307Medicare PIN
LA1549029Medicaid
LAG86683Medicare UPIN
5E307Medicare ID - Type Unspecified