Provider Demographics
NPI:1356401871
Name:D'ANGELO, DOMENIC A (OD)
Entity type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:A
Last Name:D'ANGELO
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 1:600 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3201
Mailing Address - Country:US
Mailing Address - Phone:781-231-2330
Mailing Address - Fax:781-233-2050
Practice Address - Street 1:600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3201
Practice Address - Country:US
Practice Address - Phone:781-231-2330
Practice Address - Fax:781-233-2050
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0353221Medicaid
MA401558Medicare ID - Type Unspecified