Provider Demographics
NPI:1962677146
Name:DEVARAJ, REENA
Entity Type:Individual
Prefix:MRS
First Name:REENA
Middle Name:
Last Name:DEVARAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:REENA
Other - Middle Name:
Other - Last Name:DEVARAJ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:16420 PERRIS BLVD STE Q
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1136
Mailing Address - Country:US
Mailing Address - Phone:951-571-2450
Mailing Address - Fax:915-571-2455
Practice Address - Street 1:16420 PERRIS BLVD STE Q
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1136
Practice Address - Country:US
Practice Address - Phone:951-571-2450
Practice Address - Fax:915-571-2455
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962677146Medicaid
CA1962677146Medicaid