Provider Demographics
NPI:1861993644
Name:GOVINDARAJALU, RAJARAGHAVAN
Entity type:Individual
Prefix:
First Name:RAJARAGHAVAN
Middle Name:
Last Name:GOVINDARAJALU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47600 ROYAL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5463
Mailing Address - Country:US
Mailing Address - Phone:248-722-1156
Mailing Address - Fax:
Practice Address - Street 1:47600 ROYAL POINTE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5463
Practice Address - Country:US
Practice Address - Phone:248-722-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG153730730341OtherDRIVER LICENSE
MI5501007690OtherBOARD OF PHYSICAL THERAPY