Provider Demographics
NPI:1013123025
Name:LAX, DEVAN NEAL (DPM)
Entity Type:Individual
Prefix:DR
First Name:DEVAN
Middle Name:NEAL
Last Name:LAX
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:DEVAN
Other - Middle Name:
Other - Last Name:LAX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:200 CLINTON STREET
Mailing Address - Street 2:APT 4G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:718-422-0224
Mailing Address - Fax:714-965-3620
Practice Address - Street 1:199 VALENTINE LANE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705
Practice Address - Country:US
Practice Address - Phone:914-965-1600
Practice Address - Fax:914-965-3620
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005204213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02244JMedicare PIN
U59957Medicare UPIN