Provider Demographics
NPI:1942204508
Name:DEVINE, THOMAS D (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:DEVINE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2000 ROOSEVELT RD
Mailing Address - Street 2:STE 5
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2800
Mailing Address - Country:US
Mailing Address - Phone:219-464-2123
Mailing Address - Fax:219-465-0032
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:STE 5
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-464-2123
Practice Address - Fax:219-465-0032
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-03-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01054517A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200148470Medicaid
IN200148470AMedicaid
IN200148470AMedicaid
ING47819Medicare UPIN