Provider Demographics
NPI:1063482461
Name:DEVRIES, NICHOLAS (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LINCOLN CIR SE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1836
Mailing Address - Country:US
Mailing Address - Phone:712-737-4984
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN CIR SE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-1862
Practice Address - Country:US
Practice Address - Phone:712-737-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA222782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3034231Medicaid
IA60074OtherBCBS TECHNICAL
IA44261OtherBCBS PROFESSIONAL
IA44261Medicare ID - Type Unspecified