Provider Demographics
NPI:1710963160
Name:DEVITO, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEVITO
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 1:6 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3791
Mailing Address - Country:US
Mailing Address - Phone:518-482-9111
Mailing Address - Fax:518-482-6142
Practice Address - Street 1:6 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3791
Practice Address - Country:US
Practice Address - Phone:518-482-9111
Practice Address - Fax:518-482-6142
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177478174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11208OtherGHI HMO
NM01133971Medicaid
NY000406181004OtherBLUE SHIELD
NY10000486OtherCDPHP
NY0600005OtherGHI
NY4594621OtherAETNA
NY04146OtherMVP
NY11208OtherWELLCARE
NY27F0810OtherBLUE CROSS
NY04146OtherMVP
NY000406181004OtherBLUE SHIELD