Healthcare Provider Details

I. General information

NPI: 1437526340
Provider Name (Legal Business Name): GEORGE A DEVITA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23D MEDICAL GROUP 3278 MITCHELL BLVD
MOODY AFB GA
31699-1793
US

IV. Provider business mailing address

27082 WADDINGHAM RD
EVANS MILLS NY
13637-3277
US

V. Phone/Fax

Practice location:
  • Phone: 315-783-5876
  • Fax:
Mailing address:
  • Phone: 315-783-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: