Healthcare Provider Details

I. General information

NPI: 1417033374
Provider Name (Legal Business Name): CARMELITA ANTOQUIA RAYMUNDO-DEVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARMELITA ANTOQUIA RAYMUNDO M.D.

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16455 MAIN ST. SUITE 1
HESPERIA CA
92345
US

IV. Provider business mailing address

685 CARNEGIE DR. SUITE 230
SAN BERNARDINO CA
92408-3583
US

V. Phone/Fax

Practice location:
  • Phone: 760-947-2161
  • Fax: 760-947-3673
Mailing address:
  • Phone: 909-890-0407
  • Fax: 909-890-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA55746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: