Healthcare Provider Details

I. General information

NPI: 1306409677
Provider Name (Legal Business Name): DEVAN HIGGINBOTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

IV. Provider business mailing address

1270 E SPRUCE AVE
FRESNO CA
93720-3312
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-3526
  • Fax:
Mailing address:
  • Phone: 916-734-3526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number196222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: