Basic Information
Provider Information | |||||||||
NPI: | 1902959570 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEVARAJ | ||||||||
FirstName: | CHANDER | ||||||||
MiddleName: | ERODE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1345 RXR PLAZA | ||||||||
Address2: |   | ||||||||
City: | UNIONDALE | ||||||||
State: | NY | ||||||||
PostalCode: | 11556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5167834600 | ||||||||
FaxNumber: | 5167834612 | ||||||||
Practice Location | |||||||||
Address1: | 336 E 86TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100284615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127723627 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 06/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 035401 | CT | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 216586 | NY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.