Provider Demographics
NPI:1205141074
Name:DEVORA, EDAN M (DPT)
Entity type:Individual
Prefix:
First Name:EDAN
Middle Name:M
Last Name:DEVORA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 N STATE COLLEGE BLVD
Mailing Address - Street 2:APT 4058
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-5700
Mailing Address - Country:US
Mailing Address - Phone:210-364-1493
Mailing Address - Fax:
Practice Address - Street 1:5475 E LA PALMA AVE
Practice Address - Street 2:200
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2075
Practice Address - Country:US
Practice Address - Phone:714-701-0479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist