Provider Demographics
NPI:1043264781
Name:DEVEREAUX, ROBERT ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLAN
Last Name:DEVEREAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
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:STE 100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-957-9389
Practice Address - Fax:714-957-0144
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A314750Medicaid
CA00A314750Medicaid
A31475Medicare ID - Type Unspecified