Provider Demographics
NPI:1578583373
Name:DEVANESON, PAUL P (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:P
Last Name:DEVANESON
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 1:2225 SW 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7026
Mailing Address - Country:US
Mailing Address - Phone:405-680-8856
Mailing Address - Fax:405-680-7176
Practice Address - Street 1:2225 SW 59TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7026
Practice Address - Country:US
Practice Address - Phone:405-680-8856
Practice Address - Fax:405-680-7176
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8465207P00000X, 207Q00000X, 207RG0300X
OK11656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140331342Medicaid
1611557OtherECFMG
OK200076810BMedicaid
B22233Medicare UPIN
OK200076810BMedicaid