Basic Information
| Provider Information | |||||||||
| NPI: | 1780630863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVITO | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45923 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212975923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779690392 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 125 JANAF SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235022501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574613101 | ||||||||
| FaxNumber: | 7574616942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000289 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 453835 | 01 | VA | BCBS | OTHER | 009236449 | 05 | VA | MEDICAID | 4323400003 | 01 | DME | OTHER |