Provider Demographics
NPI:1619298262
Name:GHODASRA, DEVON (MD)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:GHODASRA
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 1:320 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4709
Mailing Address - Country:US
Mailing Address - Phone:423-756-1512
Mailing Address - Fax:
Practice Address - Street 1:1605 WILLIAMS RD
Practice Address - Street 2:STE 201
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4934
Practice Address - Country:US
Practice Address - Phone:423-756-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54508207WX0107X
PAMT197686390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3715425Medicare PIN