Provider Demographics
NPI:1871803650
Name:SHANTHI DEVARAJ, M.D., LLC
Entity type:Organization
Organization Name:SHANTHI DEVARAJ, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-323-8700
Mailing Address - Street 1:1400 BEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5200
Mailing Address - Country:US
Mailing Address - Phone:203-323-8700
Mailing Address - Fax:203-323-1785
Practice Address - Street 1:1400 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5200
Practice Address - Country:US
Practice Address - Phone:203-323-8700
Practice Address - Fax:203-323-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty