Provider Demographics
NPI:1295853802
Name:DEVERA, NICANOR D (MD)
Entity type:Individual
Prefix:DR
First Name:NICANOR
Middle Name:D
Last Name:DEVERA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:531 PEBBLE BROOK LN
Mailing Address - Street 2:HMAI
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-7609
Mailing Address - Country:US
Mailing Address - Phone:618-779-5508
Mailing Address - Fax:618-206-8588
Practice Address - Street 1:6150 OAKLAND AVE
Practice Address - Street 2:CO MARILYN KORNBERGER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3215
Practice Address - Country:US
Practice Address - Phone:314-768-3090
Practice Address - Fax:314-768-3031
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR8B11207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A13787Medicare UPIN