Healthcare Provider Details

I. General information

NPI: 1306308549
Provider Name (Legal Business Name): RAKHEE SHIRISH DEVASTHALI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WILLIAM VICKERS AVE
DURHAM NC
27701-2792
US

IV. Provider business mailing address

607 WILLIAM VICKERS AVE
DURHAM NC
27701-2792
US

V. Phone/Fax

Practice location:
  • Phone: 919-899-1720
  • Fax: 919-578-8773
Mailing address:
  • Phone: 919-899-1720
  • Fax: 919-578-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2021-00164
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: