Provider Demographics
NPI:1972550531
Name:W. C. DEAVOR, M.D.,P.C.
Entity Type:Organization
Organization Name:W. C. DEAVOR, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAVOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-875-2134
Mailing Address - Street 1:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36702-1470
Mailing Address - Country:US
Mailing Address - Phone:334-875-2134
Mailing Address - Fax:334-875-4331
Practice Address - Street 1:203 VAUGHAN MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6950
Practice Address - Country:US
Practice Address - Phone:334-875-2134
Practice Address - Fax:334-875-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00003867174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01697OtherBLUE CROSS BLUE SHIELD
AL01697OtherBLUE CROSS BLUE SHIELD