Healthcare Provider Details

I. General information

NPI: 1104972025
Provider Name (Legal Business Name): MARY LOU DEVAUL - ESHLEMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 OSBORNE ST
ST MARYS GA
31558-1331
US

IV. Provider business mailing address

605 OSBORNE ST
SAINT MARYS GA
31558-8410
US

V. Phone/Fax

Practice location:
  • Phone: 919-946-2702
  • Fax:
Mailing address:
  • Phone: 919-946-2702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number68402
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: