Provider Demographics
NPI:1861477853
Name:DEVAULT, GEORGE A JR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:DEVAULT
Suffix:JR
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 1:1914 LELARAY ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2800
Mailing Address - Country:US
Mailing Address - Phone:719-632-7641
Mailing Address - Fax:719-632-2925
Practice Address - Street 1:1914 LELARAY ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2800
Practice Address - Country:US
Practice Address - Phone:719-632-7641
Practice Address - Fax:719-632-2925
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37136207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1371368Medicaid
CO1371368Medicaid
85064Medicare ID - Type Unspecified