Provider Demographics
NPI:1407829658
Name:DEVERA, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:DEVERA
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 1:25865 BARTON ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-3636
Mailing Address - Fax:909-558-3722
Practice Address - Street 1:25865 BARTON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-3636
Practice Address - Fax:909-558-3722
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053830L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001886783Medicaid
PA055378FKYMedicare ID - Type Unspecified
PAH05428Medicare UPIN