Healthcare Provider Details

I. General information

NPI: 1396009734
Provider Name (Legal Business Name): DEEPA NAGARAJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 LAKE AVE STE 120
PUEBLO CO
81004-3878
US

IV. Provider business mailing address

3426 LAKE AVE STE 120
PUEBLO CO
81004-3878
US

V. Phone/Fax

Practice location:
  • Phone: 719-561-5264
  • Fax:
Mailing address:
  • Phone: 719-561-5264
  • Fax: 719-561-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberDR.0059953
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: