Provider Demographics
NPI:1861460214
Name:KOLISETTI, RAJA (MD)
Entity type:Individual
Prefix:
First Name:RAJA
Middle Name:
Last Name:KOLISETTI
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:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14021-0333
Mailing Address - Country:US
Mailing Address - Phone:585-703-0101
Mailing Address - Fax:
Practice Address - Street 1:2 W MAIN ST UNIT 333
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14021-7013
Practice Address - Country:US
Practice Address - Phone:585-703-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU4548207Q00000X
NY185959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0160325Medicaid
NYBA0156Medicare PIN
NY0160325Medicaid