Provider Demographics
NPI:1114927688
Name:DANGELO, CARMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:
Last Name:DANGELO
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 1:485 TITUS AVE
Mailing Address - Street 2:STE D
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-3535
Mailing Address - Country:US
Mailing Address - Phone:585-544-5368
Mailing Address - Fax:585-544-0036
Practice Address - Street 1:485 TITUS AVE
Practice Address - Street 2:STE D
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-3535
Practice Address - Country:US
Practice Address - Phone:585-544-5368
Practice Address - Fax:585-544-0036
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163205-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101108BJOtherPREFERRED CARE
NY01065296Medicaid
NY101108BJOtherPREFERRED CARE
NYRA4390Medicare ID - Type UnspecifiedMEDICARE INDIV