Provider Demographics
NPI:1356796700
Name:RAJ, MAMTHA (MD, MA)
Entity type:Individual
Prefix:
First Name:MAMTHA
Middle Name:
Last Name:RAJ
Suffix:
Gender:F
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 425
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3893
Mailing Address - Country:US
Mailing Address - Phone:312-563-3000
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 425
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3893
Practice Address - Country:US
Practice Address - Phone:312-563-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66577208200000X
PAMT210474208200000X
IL036166530208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery