Provider Demographics
NPI:1154632503
Name:DEVGON, SHIVALI (MD)
Entity Type:Individual
Prefix:
First Name:SHIVALI
Middle Name:
Last Name:DEVGON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 DELMORE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1534
Mailing Address - Country:US
Mailing Address - Phone:218-463-1365
Mailing Address - Fax:218-463-3928
Practice Address - Street 1:711 DELMORE DR
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-1365
Practice Address - Fax:218-463-3928
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110016132Medicare PIN