Provider Demographics
NPI:1356344717
Name:DEVORE, RICHARD ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:DEVORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2125
Mailing Address - Country:US
Mailing Address - Phone:937-283-9845
Mailing Address - Fax:937-283-9839
Practice Address - Street 1:630 W MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2172
Practice Address - Country:US
Practice Address - Phone:937-283-9800
Practice Address - Fax:937-283-9794
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR150885207Y00000X
OH35-058294207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0802804Medicaid
OH040015410OtherRR MEDICARE
OH0802804Medicaid
OHE29742Medicare UPIN