Healthcare Provider Details

I. General information

NPI: 1063658623
Provider Name (Legal Business Name): VIDYA RAJARAM DEVARAJAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-1512
  • Fax:
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number92500
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number44007
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: