Provider Demographics
NPI:1457462178
Name:MICHILLI, ANGELO DOMENIC (DO)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:DOMENIC
Last Name:MICHILLI
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 1:1610 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-6289
Mailing Address - Country:US
Mailing Address - Phone:718-409-6400
Mailing Address - Fax:718-823-9119
Practice Address - Street 1:1610 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6289
Practice Address - Country:US
Practice Address - Phone:718-409-6400
Practice Address - Fax:718-823-9119
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
22N871Medicare ID - Type Unspecified
NYG47400Medicare UPIN