Provider Demographics
NPI:1205052990
Name:THIAGARAJAN, DEEPAK (MD)
Entity type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:THIAGARAJAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 RODEO RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-2408
Mailing Address - Country:US
Mailing Address - Phone:909-881-5994
Mailing Address - Fax:909-248-7769
Practice Address - Street 1:7974 HAVEN AVE STE 210
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3052
Practice Address - Country:US
Practice Address - Phone:909-881-5994
Practice Address - Fax:909-248-7769
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12318207R00000X
RILP00988207RG0300X
CAA 113059207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI414203OtherBLUECHIP
RIDT68425Medicaid
RIAA91479OtherHPHC - MIRIAM
RI32935-4OtherBCBS
RIAA91479OtherHPHC - MIRIAM