Provider Demographics
NPI:1710541438
Name:DEVINE, JOHN C (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:DEVINE
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 1:23939 CO RT 59
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634
Mailing Address - Country:US
Mailing Address - Phone:315-778-3592
Mailing Address - Fax:
Practice Address - Street 1:15 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1163
Practice Address - Country:US
Practice Address - Phone:315-265-9271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315559208000000X
NC250480390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program