Healthcare Provider Details

I. General information

NPI: 1639193204
Provider Name (Legal Business Name): JEGADEES DEVANESAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 W SAGAMORE AVE
CLEWISTON FL
33440-3514
US

IV. Provider business mailing address

540 W SAGAMORE AVE
CLEWISTON FL
33440-3514
US

V. Phone/Fax

Practice location:
  • Phone: 863-983-5026
  • Fax: 863-983-2973
Mailing address:
  • Phone: 863-983-5026
  • Fax: 863-983-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME35369
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: