Provider Demographics
NPI:1528007515
Name:DEVELLIS, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:DEVELLIS
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 1:92 HIGH ST
Mailing Address - Street 2:SUITE 32
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3850
Mailing Address - Country:US
Mailing Address - Phone:781-395-5250
Mailing Address - Fax:
Practice Address - Street 1:92 HIGH ST
Practice Address - Street 2:SUITE 32
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3850
Practice Address - Country:US
Practice Address - Phone:781-395-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery