1417033374 NPI number — DR. CARMELITA ANTOQUIA RAYMUNDO-DEVERA M.D.

Table of content: DR. CARMELITA ANTOQUIA RAYMUNDO-DEVERA M.D. (NPI 1417033374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417033374 NPI number — DR. CARMELITA ANTOQUIA RAYMUNDO-DEVERA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAYMUNDO-DEVERA
Provider First Name:
CARMELITA
Provider Middle Name:
ANTOQUIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAYMUNDO
Provider Other First Name:
CARMELITA
Provider Other Middle Name:
ANTOQUIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1417033374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
685 CARNEGIE DR.
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92408-3583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-890-0407
Provider Business Mailing Address Fax Number:
909-890-0575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16455 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-947-2161
Provider Business Practice Location Address Fax Number:
760-947-3673
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A55746 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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