Basic Information
| Provider Information | |||||||||
| NPI: | 1851595912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVITRE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GUSTAD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6210 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874996210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092258 | ||||||||
| FaxNumber: | 5056092259 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056096463 | ||||||||
| FaxNumber: | 5056096474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2007006876 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 2007006876 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | A-1522-09 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A-1522-09 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.