Provider Demographics
NPI:1053597641
Name:ASHA DEVEREAUX, MD, MPH A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ASHA DEVEREAUX, MD, MPH A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:V
Authorized Official - Last Name:DEVEREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-435-4203
Mailing Address - Street 1:1224 10TH ST
Mailing Address - Street 2:STE 205
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3416
Mailing Address - Country:US
Mailing Address - Phone:619-435-4203
Mailing Address - Fax:
Practice Address - Street 1:1224 10TH ST
Practice Address - Street 2:STE 205
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3416
Practice Address - Country:US
Practice Address - Phone:619-435-4203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A516140Medicaid
CAA51614Medicare PIN
CAH80388Medicare UPIN