Provider Demographics
NPI:1578636072
Name:DEVAUGHN, GERALD LANE (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:LANE
Last Name:DEVAUGHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5249 CEDAR AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1524
Mailing Address - Country:US
Mailing Address - Phone:215-471-1817
Mailing Address - Fax:215-471-5089
Practice Address - Street 1:5249 CEDAR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1524
Practice Address - Country:US
Practice Address - Phone:215-471-1817
Practice Address - Fax:215-471-5089
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024220E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009504130009Medicaid
PA0009504130009Medicaid
B34932Medicare UPIN