Provider Demographics
NPI:1205849155
Name:DEVON, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:DEVON
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 1:8 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2824
Mailing Address - Country:US
Mailing Address - Phone:617-387-3851
Mailing Address - Fax:781-979-0555
Practice Address - Street 1:8 PORTER ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2824
Practice Address - Country:US
Practice Address - Phone:617-387-3851
Practice Address - Fax:781-979-0555
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42568208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2060574Medicaid
MAB17066Medicare UPIN
MAM13339Medicare UPIN