MEDICARE: DR. KIMBERLY M DEVOLLD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	ME86723	FL
2	208000000X	Pediatrics Physician	35094744	OH
3	208000000X	Pediatrics Physician	0101241911	VA
4	208000000X	Pediatrics Physician	43204	TN
5	208000000X	Pediatrics Physician	MD40634	SC
6	2080B0002X	Pediatric Obesity Medicine Physician	0101241911	VA
7	2080B0002X	Pediatric Obesity Medicine Physician	MD40634	SC
8	208D00000X	General Practice Physician	0101241911	VA
9	208D00000X	General Practice Physician	MD40634	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225028806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY M DEVOLLD M.D.

Provider Business Mailing Address
First Line	:	2754 MAYBANK HWY STE B
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-996-4908
Fax Number	:	843-962-5450

Provider Business Practice Location Address
First Line	:	2754 MAYBANK HWY STE B
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4809
Country	:	US
Telephone Number	:	843-996-4908
Fax Number	:	843-962-5450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/15/2022

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Directions to “ DR. KIMBERLY M DEVOLLD M.D.” Practice Location

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