Provider Demographics
NPI:1508829714
Name:DURAIRAJ, DAMAYANTHI (MD)
Entity Type:Individual
Prefix:
First Name:DAMAYANTHI
Middle Name:
Last Name:DURAIRAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19726 SEGOVIA LN
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-2841
Mailing Address - Country:US
Mailing Address - Phone:909-881-7320
Mailing Address - Fax:909-881-7329
Practice Address - Street 1:1574 W BASE LINE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1736
Practice Address - Country:US
Practice Address - Phone:909-386-1880
Practice Address - Fax:909-386-1882
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A39805208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE78443Medicare UPIN
CA00A398050Medicare ID - Type Unspecified
CA00A398052Medicare UPIN