MEDICARE: SAMUEL DEVICTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YS0123X	Facial Plastic Surgery Physician	68902	AZ

General Provider Information

NPI Number	:	1619301884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL DEVICTOR

Provider Business Mailing Address
First Line	:	5310 HARVEST HILL RD STE 290
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-5826
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11130 N TATUM BLVD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1630
Country	:	US
Telephone Number	:	602-737-1361
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2013
Last Update Date	:	08/24/2023

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Directions to “ SAMUEL DEVICTOR ” Practice Location

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