Provider Demographics
NPI:1750495792
Name:DEVENECIA, LUIS C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:C
Last Name:DEVENECIA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1200 N EAST ST
Mailing Address - Street 2:WEBER MEDICAL CLINIC
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2432
Mailing Address - Country:US
Mailing Address - Phone:618-395-5222
Mailing Address - Fax:618-395-8552
Practice Address - Street 1:1200 N EAST ST
Practice Address - Street 2:WEBER MEDICAL CLINIC
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2432
Practice Address - Country:US
Practice Address - Phone:618-395-5222
Practice Address - Fax:618-395-8552
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036091236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL063073OtherHEALTH ALLIANCE
IL296286OtherHEALTH LINK
IL036091236Medicaid
IL296286OtherHEALTH LINK
G42025Medicare UPIN