Provider Demographics
NPI:1578023727
Name:DEVENNEY, NATHAN MARK (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:MARK
Last Name:DEVENNEY
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 1:95 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7001
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:
Practice Address - Street 1:95 CRYSTAL RUN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7001
Practice Address - Country:US
Practice Address - Phone:845-703-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324545208000000X
IL125.074934208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics