Basic Information
| Provider Information | |||||||||
| NPI: | 1861477853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVAULT | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1914 LELARAY ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809092800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196327641 | ||||||||
| FaxNumber: | 7196322925 | ||||||||
| Practice Location | |||||||||
| Address1: | 1914 LELARAY ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809092800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196327641 | ||||||||
| FaxNumber: | 7196322925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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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 | 207RN0300X | 37136 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 37136 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1371368 | 05 | CO | MEDICAID |