Provider Demographics
NPI:1043698798
Name:DEANGELO, ANTHONY VINCENT
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:VINCENT
Last Name:DEANGELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6202
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:
Practice Address - Street 1:11501 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3313
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT18299OtherFLORIDA DEPARTMENT OF HEALTH LICENSE