Healthcare Provider Details

I. General information

NPI: 1477832517
Provider Name (Legal Business Name): CHENTHURAN DEIVARAJU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE STE 301
LAS CRUCES NM
88011-8262
US

IV. Provider business mailing address

4351 E LOHMAN AVE STE 301
LAS CRUCES NM
88011-8262
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9755
  • Fax: 575-532-8881
Mailing address:
  • Phone: 575-532-9755
  • Fax: 575-532-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number60558-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME121046
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2014-0664
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: