=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245643956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA DEVARAJ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2014
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 MARKET ST STE B
-----------------------------------------------------
City | CAMP HILL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17011-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-691-1212
-----------------------------------------------------
Fax | 717-691-5354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 858 MC 410
-----------------------------------------------------
City | HERSHEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17033-0858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-243-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | MT206104
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD460966
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------