Provider Demographics
NPI:1851462329
Name:DEVINE, DANIEL (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DEVINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 RAMBLING CT
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-6635
Mailing Address - Country:US
Mailing Address - Phone:423-639-3187
Mailing Address - Fax:
Practice Address - Street 1:3000 MALL ROAD NORTH
Practice Address - Street 2:KNOXVILLE CENTER MALL
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924
Practice Address - Country:US
Practice Address - Phone:865-521-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1774152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3942583Medicaid
VA010300568Medicaid
TN39425841Medicaid
TN3942584Medicare PIN
TN39425841Medicaid
U75228Medicare UPIN