Provider Demographics
NPI:1770564825
Name:ANDERSON, DEVONA R (MD)
Entity type:Individual
Prefix:
First Name:DEVONA
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1412 N DELPHOS ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2565
Mailing Address - Country:US
Mailing Address - Phone:765-416-1612
Mailing Address - Fax:313-789-1822
Practice Address - Street 1:1542 S DIXON RD STE B
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-7319
Practice Address - Country:US
Practice Address - Phone:765-416-1612
Practice Address - Fax:313-789-1822
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2024-12-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01061169A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11517013OtherCAQH
IN200530410Medicaid
11517013OtherCAQH
INI05968Medicare UPIN
INP01328706Medicare PIN