Healthcare Provider Details

I. General information

NPI: 1215909718
Provider Name (Legal Business Name): WILLIAM LEONARD DEVAULT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

V. Phone/Fax

Practice location:
  • Phone: 618-546-1294
  • Fax: 618-546-2665
Mailing address:
  • Phone: 618-546-1294
  • Fax: 618-546-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number201301122
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101043815
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036145174
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: