Basic Information
| Provider Information | |||||||||
| NPI: | 1518353820 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DEVRIES | ||||||||
| FirstName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LIBERTY ST STE 1A | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085650232 | ||||||||
| FaxNumber: | 5088940757 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LIBERTY ST STE 1A | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085650232 | ||||||||
| FaxNumber: | 5088940757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5747 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 280645 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 67371 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0010X | 280645 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
No ID Information.