Provider Demographics
NPI:1538344189
Name:ROBERT A. DEVEREAUX, M.D., INC.
Entity type:Organization
Organization Name:ROBERT A. DEVEREAUX, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:DEVEREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-957-9389
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-957-9389
Mailing Address - Fax:714-957-0144
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-957-9389
Practice Address - Fax:714-957-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31475261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A314750Medicaid
CA00A314750Medicaid
A26497Medicare UPIN
A31475Medicare PIN