Provider Demographics
NPI:1023098555
Name:DEVORE, JACK (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:DEVORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 NORMANSKILL BLVD
Mailing Address - Street 2:SUITE 400
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:SUITE 400
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10034805OtherCDPHP
NYC6476OtherEMPIRE BC
NY000495454001OtherBS NENY
NY410044002OtherRAILRAOD MEDICARE
NY01419103Medicaid
NY59336OtherMVP
BB8388Medicare ID - Type Unspecified
NY01419103Medicaid