MEDICARE: NR DEVARAJ MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A34201	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821175118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NR DEVARAJ MD INC

Provider Business Mailing Address
First Line	:	3356 W BALL RD SUITE 205
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3737
Country	:	US
Telephone Number	:	714-952-0958
Fax Number	:	714-952-0719

Provider Business Practice Location Address
First Line	:	3356 W. BALL RD SUITE 205
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3737
Country	:	US
Telephone Number	:	714-952-0958
Fax Number	:	714-952-0719

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ROSIE FRAUSTO
Credential	:
Telephone Number	:	714-952-0958

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	10/08/2020

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