Basic Information
| Provider Information | |||||||||
| NPI: | 1205052990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIAGARAJAN | ||||||||
| FirstName: | DEEPAK | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7755 CENTER AVE STE 630 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926479152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6574005014 | ||||||||
| FaxNumber: | 8446987227 | ||||||||
| Practice Location | |||||||||
| Address1: | 7755 CENTER AVE STE 630 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926479152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6574005014 | ||||||||
| FaxNumber: | 8446987227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | LP00988 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | MD12318 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | A 113059 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32935-4 | 01 | RI | BCBS | OTHER | 414203 | 01 | RI | BLUECHIP | OTHER | AA91479 | 01 | RI | HPHC - MIRIAM | OTHER | DT68425 | 05 | RI | MEDICAID |