Provider Demographics
NPI:1053328682
Name:DEVRIES, JON P (MD)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:P
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9100 MEDCOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9167
Mailing Address - Country:US
Mailing Address - Phone:843-569-3367
Mailing Address - Fax:843-764-3577
Practice Address - Street 1:9100 MEDCOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9167
Practice Address - Country:US
Practice Address - Phone:843-569-3367
Practice Address - Fax:843-764-3577
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22480207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT67308Medicaid
SC3204Medicare PIN
H38158Medicare UPIN