Basic Information
| Provider Information | |||||||||
| NPI: | 1295153021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVARAJ | ||||||||
| FirstName: | LILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176432401 | ||||||||
| FaxNumber: | 6177243947 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176432401 | ||||||||
| FaxNumber: | 6177243947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125065920 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 125065920 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 274250 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 274250 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.