Provider Demographics
NPI:1821175118
Name:NR DEVARAJ MD INC
Entity Type:Organization
Organization Name:NR DEVARAJ MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAUSTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-952-0958
Mailing Address - Street 1:3356 W BALL RD SUITE 205
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3737
Mailing Address - Country:US
Mailing Address - Phone:714-952-0958
Mailing Address - Fax:714-952-0719
Practice Address - Street 1:3356 W. BALL RD SUITE 205
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3737
Practice Address - Country:US
Practice Address - Phone:714-952-0958
Practice Address - Fax:714-952-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A342010Medicaid
CAW19787Medicare PIN
CAA88074Medicare UPIN