Healthcare Provider Details

I. General information

NPI: 1689686149
Provider Name (Legal Business Name): DEVITT ELVERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

IV. Provider business mailing address

115 BEACH 221ST ST
ROCKAWAY POINT NY
11697-1524
US

V. Phone/Fax

Practice location:
  • Phone: 718-616-4408
  • Fax: 718-616-4105
Mailing address:
  • Phone: 718-634-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number159563-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: