Provider Demographics
NPI:1619108164
Name:VENKAT DEVINENI, MD, INC
Entity Type:Organization
Organization Name:VENKAT DEVINENI, MD, INC
Other - Org Name:RADIANT HEART INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-951-7778
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:
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:92395-7787
Practice Address - Country:US
Practice Address - Phone:760-951-7778
Practice Address - Fax:760-951-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54340261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A543400Medicaid
CA00A543400Medicare PIN