Healthcare Provider Details

I. General information

NPI: 1982905717
Provider Name (Legal Business Name): CHARLES DEVINE, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 E BLOOMINGDALE AVE
BRANDON FL
33511-8155
US

IV. Provider business mailing address

336 E BLOOMINGDALE AVE
BRANDON FL
33511-8155
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-2466
  • Fax: 813-689-0435
Mailing address:
  • Phone: 813-689-2466
  • Fax: 813-689-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME0072537
License Number StateFL

VIII. Authorized Official

Name: DR. CHARLES DEVINE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 813-689-2466