Provider Demographics
NPI:1821259474
Name:BOMMADEVARA, DEEPTHI K (MD; MPH)
Entity Type:Individual
Prefix:
First Name:DEEPTHI
Middle Name:K
Last Name:BOMMADEVARA
Suffix:
Gender:F
Credentials:MD; MPH
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:111 CONTINENTAL DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4306
Mailing Address - Country:US
Mailing Address - Phone:302-368-2630
Mailing Address - Fax:302-368-1271
Practice Address - Street 1:111 CONTINENTAL DR
Practice Address - Street 2:SUITE 406
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4306
Practice Address - Country:US
Practice Address - Phone:302-368-2630
Practice Address - Fax:302-368-1271
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC1-0009777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1821259474Medicaid
DE226452ZAG8Medicare PIN