Healthcare Provider Details

I. General information

NPI: 1639424906
Provider Name (Legal Business Name): MICHAEL RYAN DEVARONA D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-5505
  • Fax:
Mailing address:
  • Phone: 305-243-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS11739
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: