Healthcare Provider Details

I. General information

NPI: 1245258425
Provider Name (Legal Business Name): DAVID DEVENPORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672 W. 400 S. SUITE 101
SPRINGVILLE UT
84663
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-491-9883
  • Fax: 801-489-3141
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number290516-1205
License Number StateUT

VII. Legacy identifiers

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

# 1
IdentifierD3263
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: