Provider Demographics
NPI:1679762702
Name:GREGGORY R. DEVORE M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GREGGORY R. DEVORE M.D. A MEDICAL CORPORATION
Other - Org Name:FETAL DIAGNOSTIC CENTER OF PASADENA, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGGORY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-583-8911
Mailing Address - Street 1:50 ALESSANDRO PL STE 330
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3187
Mailing Address - Country:US
Mailing Address - Phone:626-583-8911
Mailing Address - Fax:626-583-8894
Practice Address - Street 1:50 ALESSANDRO PL STE 330
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3187
Practice Address - Country:US
Practice Address - Phone:626-583-8911
Practice Address - Fax:626-583-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44446174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G444460Medicaid
CA00G444461Medicaid
CA1679762702Medicaid