Provider Demographics
NPI:1073004800
Name:DEVORE, NATHAN MARK (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:MARK
Last Name:DEVORE
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 1:2365 EDISON BLVD
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-2388
Mailing Address - Country:US
Mailing Address - Phone:216-553-7443
Mailing Address - Fax:
Practice Address - Street 1:2365 EDISON BLVD
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-2388
Practice Address - Country:US
Practice Address - Phone:216-553-7430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.140913207Q00000X
MEEC181039390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program