Provider Demographics
NPI:1639201429
Name:BRUCE DEVON, M.D., P.C.
Entity Type:Organization
Organization Name:BRUCE DEVON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-387-3851
Mailing Address - Street 1:8 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2824
Mailing Address - Country:US
Mailing Address - Phone:617-387-3851
Mailing Address - Fax:781-979-0555
Practice Address - Street 1:8 PORTER ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2824
Practice Address - Country:US
Practice Address - Phone:617-387-3851
Practice Address - Fax:781-979-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42568208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2060574Medicaid
MAB17066Medicare UPIN
MA2060574Medicaid
MAM13339Medicare ID - Type Unspecified