Provider Demographics
NPI:1104449362
Name:DEVERA, JUSTIN JAMES D (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN JAMES
Middle Name:D
Last Name:DEVERA
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 100267 BOX 1663
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09588-6716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:BUILDING 3, INTERNAL MEDICINE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134
Practice Address - Country:US
Practice Address - Phone:619-532-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206754208D00000X, 390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1104449362Medicaid