Provider Demographics
NPI:1649932245
Name:DEVADOSS, JOSEPHINE
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:DEVADOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 VILLA CREEK DR STE 205A
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2665 VILLA CREEK DR
Practice Address - Street 2:STE 205A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7337
Practice Address - Country:US
Practice Address - Phone:469-278-3736
Practice Address - Fax:972-499-9009
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10547491171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10547491OtherDRIVER LICENCE