Provider Demographics
NPI:1588650675
Name:DEVINENI, VENKAT (MD)
Entity Type:Individual
Prefix:MR
First Name:VENKAT
Middle Name:
Last Name:DEVINENI
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 1537
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-1537
Mailing Address - Country:US
Mailing Address - Phone:760-951-7778
Mailing Address - Fax:760-241-5950
Practice Address - Street 1:17259 JASMINE ST
Practice Address - Street 2:SUITE B
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-951-7778
Practice Address - Fax:760-241-5950
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54340207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00454301Medicaid
CA00454301Medicaid
00A543400Medicare ID - Type Unspecified