Provider Demographics
NPI:1053454058
Name:DEVINE, CHARLES JOSEPH III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:DEVINE
Suffix:III
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 1:434 WASHINGTON ST.
Mailing Address - Street 2:PO BOX 560
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917
Mailing Address - Country:US
Mailing Address - Phone:434-738-6815
Mailing Address - Fax:434-738-6295
Practice Address - Street 1:434 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917
Practice Address - Country:US
Practice Address - Phone:434-738-6815
Practice Address - Fax:434-738-6295
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010345182083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5811007Medicaid
VAB05068Medicare UPIN