Provider Demographics
NPI:1952334443
Name:DEVARAKONDA & RAJENDRAN MD S
Entity Type:Organization
Organization Name:DEVARAKONDA & RAJENDRAN MD S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBRANMANYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVARAKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-752-1053
Mailing Address - Street 1:1507 W REYNOLDS ST
Mailing Address - Street 2:STE B
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4702
Mailing Address - Country:US
Mailing Address - Phone:813-752-1053
Mailing Address - Fax:813-754-6739
Practice Address - Street 1:1507 W REYNOLDS ST
Practice Address - Street 2:STE B
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4702
Practice Address - Country:US
Practice Address - Phone:813-752-1053
Practice Address - Fax:813-754-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98568OtherBCBS
FLCB7529OtherRAILROAD
FL060981100Medicaid
FL060981100Medicaid