Provider Demographics
NPI:1578668364
Name:DEANGELIS, GARY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:DEANGELIS
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 1:1550 OVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219
Mailing Address - Country:US
Mailing Address - Phone:646-626-0892
Mailing Address - Fax:
Practice Address - Street 1:1550 OVINGTON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-256-1570
Practice Address - Fax:718-837-1412
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00546103Medicaid
B11119Medicare UPIN
NY22A291Medicare ID - Type Unspecified