Healthcare Provider Details

I. General information

NPI: 1710418876
Provider Name (Legal Business Name): DEVON WAYNE CONSUL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WILSON BRIDGE RD STE 200
WORTHINGTON OH
43085-2591
US

IV. Provider business mailing address

350 W WILSON BRIDGE RD STE 200
WORTHINGTON OH
43085-2591
US

V. Phone/Fax

Practice location:
  • Phone: 614-895-8747
  • Fax:
Mailing address:
  • Phone: 614-895-8747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003983
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: