Provider Demographics
NPI:1760735492
Name:DEVADER MEDICAL & RESEARCH GROUP,INC.
Entity Type:Organization
Organization Name:DEVADER MEDICAL & RESEARCH GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-331-8390
Mailing Address - Street 1:175 N REDWOOD DR
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1972
Mailing Address - Country:US
Mailing Address - Phone:415-331-8390
Mailing Address - Fax:
Practice Address - Street 1:175 N REDWOOD DR
Practice Address - Street 2:SUITE 275
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1972
Practice Address - Country:US
Practice Address - Phone:415-331-8390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty