Provider Demographics
NPI:1790766277
Name:DEVITA, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DEVITA
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 1:1640 HIGHWAY 88
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3036
Mailing Address - Country:US
Mailing Address - Phone:732-840-1900
Mailing Address - Fax:732-840-0355
Practice Address - Street 1:1640 HIGHWAY 88
Practice Address - Street 2:SUITE 201
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3036
Practice Address - Country:US
Practice Address - Phone:732-840-1900
Practice Address - Fax:732-840-0355
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06428600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0001511Medicaid
NJ0001511Medicaid
NJ064264NNGMedicare PIN