Provider Demographics
NPI:1336162502
Name:DEVINE, MATHEW J (DO)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:J
Last Name:DEVINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1448
Mailing Address - Country:US
Mailing Address - Phone:585-279-4800
Mailing Address - Fax:585-442-8319
Practice Address - Street 1:777 CLINTON AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1401
Practice Address - Country:US
Practice Address - Phone:585-279-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB7809Medicare PIN