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General NPI Number Information
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NPI Number | 1619301884
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Entity Type | Individual
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Provider Name | SAMUEL DEVICTOR
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Gender | Male
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Dates
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Enumeration Date | 08/23/2013
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 11130 N TATUM BLVD STE 100
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City | PHOENIX
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State | AZ
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Zip | 85028-1630
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Country | US
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Telephone | 602-737-1361
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Fax |
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Provider Business Mailing Address
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Address Line | 5310 HARVEST HILL RD STE 290
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City | DALLAS
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State | TX
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Zip | 75230-5826
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | 68902
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License Number State | AZ
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