Provider Demographics
NPI:1013187178
Name:JACK DEVORE, OD
Entity Type:Organization
Organization Name:JACK DEVORE, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-478-9992
Mailing Address - Street 1:4 NORMANSKILL BLVD
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1335
Mailing Address - Country:US
Mailing Address - Phone:518-478-9992
Mailing Address - Fax:518-439-0796
Practice Address - Street 1:4 NORMANSKILL BLVD
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1335
Practice Address - Country:US
Practice Address - Phone:518-478-9992
Practice Address - Fax:518-439-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003734332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY410044002OtherRAILROAD MEDICARE
NYBB8388Medicare PIN
NY410044002OtherRAILROAD MEDICARE