Provider Demographics
NPI:1912694217
Name:DOHERTY, DEVON VIVIAN RAYMUNDO
Entity Type:Individual
Prefix:
First Name:DEVON VIVIAN
Middle Name:RAYMUNDO
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CLOVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-1906
Mailing Address - Country:US
Mailing Address - Phone:626-633-7457
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4446
Practice Address - Country:US
Practice Address - Phone:209-573-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program