Provider Demographics
NPI:1073511234
Name:MCDEVITT, GORDON ROBERTS JR (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ROBERTS
Last Name:MCDEVITT
Suffix:JR
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:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-0619
Mailing Address - Country:US
Mailing Address - Phone:910-592-8070
Mailing Address - Fax:910-592-8549
Practice Address - Street 1:409C COOPER DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2817
Practice Address - Country:US
Practice Address - Phone:910-592-8070
Practice Address - Fax:910-592-8549
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94005792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56119OtherBCBS OF NC
NC8956119Medicaid
BM5128322OtherDEA
BM5128322OtherDEA
NC56119OtherBCBS OF NC