Provider Demographics
NPI:1023299609
Name:WALTER D. DEVAULT III M.D. P.A.
Entity type:Organization
Organization Name:WALTER D. DEVAULT III M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVAULT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:772-286-5551
Mailing Address - Street 1:816 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2428
Mailing Address - Country:US
Mailing Address - Phone:772-286-5551
Mailing Address - Fax:772-286-3026
Practice Address - Street 1:816 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2428
Practice Address - Country:US
Practice Address - Phone:772-286-5551
Practice Address - Fax:772-286-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35751OtherBCBS
FLK8929Medicare PIN