Provider Demographics
NPI:1699056101
Name:DEVINE, ROBERT DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DANIEL
Last Name:DEVINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18275 N 59TH AVENUE
Mailing Address - Street 2:BLDG K, SUITE 162
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1254
Mailing Address - Country:US
Mailing Address - Phone:602-547-8184
Mailing Address - Fax:602-547-8339
Practice Address - Street 1:18275 N 59TH AVENUE
Practice Address - Street 2:BLDG K, SUITE 162
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1254
Practice Address - Country:US
Practice Address - Phone:602-547-8184
Practice Address - Fax:602-547-8339
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2731207Q00000X
FLOS11891207Q00000X
AZ006273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ167775Medicare PIN