Provider Demographics
NPI:1720245582
Name:KANMANIRAJA, DEVARAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVARAJU
Middle Name:
Last Name:KANMANIRAJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-383-1024
Practice Address - Fax:904-244-8827
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2556182085R0202X
FLME1079752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159388AMedicaid
FL014508600Medicaid
FLIC575ZMedicare PIN