Basic Information
| Provider Information | |||||||||
| NPI: | 1417033374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMUNDO-DEVERA | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | ANTOQUIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAYMUNDO | ||||||||
| OtherFirstName: | CARMELITA | ||||||||
| OtherMiddleName: | ANTOQUIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 685 CARNEGIE DR. | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098900407 | ||||||||
| FaxNumber: | 9098900575 | ||||||||
| Practice Location | |||||||||
| Address1: | 16455 MAIN ST. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609472161 | ||||||||
| FaxNumber: | 7609473673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A55746 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.