Provider Demographics
NPI:1326040536
Name:DEVIVO, ANGELO JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:JOSEPH
Last Name:DEVIVO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1774 PAXVILLE HWY
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-5071
Practice Address - Country:US
Practice Address - Phone:803-435-2494
Practice Address - Fax:803-435-8765
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4531 T1261152W00000X
SC2117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD21171Medicaid
OH0104630Medicaid
OHU52111Medicare UPIN