Basic Information
Provider Information
NPI: 1417057647
EntityType: 2
ReplacementNPI:  
OrganizationName: RICHARD A. DEVORE, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
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Mailing Information
Address1: PO BOX 632603
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452630027
CountryCode: US
TelephoneNumber: 5138912813
FaxNumber: 5137931032
Practice Location
Address1: 8221 CORNELL RD
Address2: STE 410
City: CINCINNATI
State: OH
PostalCode: 452492235
CountryCode: US
TelephoneNumber: 5137916757
FaxNumber: 5137928035
Other Information
ProviderEnumerationDate: 09/25/2006
LastUpdateDate: 09/21/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DEVORE
AuthorizedOfficialFirstName: RICHARD
AuthorizedOfficialMiddleName: A
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 5137916757
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Y00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOtolaryngology 

ID Information
IDTypeStateIssuerDescription
295816105OH MEDICAID


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