Provider Demographics
NPI:1194750778
Name:MUDGE, DEVIN REED (MD)
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:REED
Last Name:MUDGE
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 1:401 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 251
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3803
Mailing Address - Country:US
Mailing Address - Phone:909-881-1614
Mailing Address - Fax:909-881-2711
Practice Address - Street 1:401 E HIGHLAND AVE
Practice Address - Street 2:SUITE 251
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3803
Practice Address - Country:US
Practice Address - Phone:909-881-1614
Practice Address - Fax:909-881-2711
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G752871OtherMEDICARE INDIVIDUAL PTAN
CA00G752870Medicaid
CAG75287OtherLICENSE
ZZZ07161ZOtherMEDICARE GROUP PTAN
CA00G752870Medicaid