Provider Demographics
NPI:1750756342
Name:MAXON, ANGELINA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:ANGELINA
Middle Name:MARIE
Last Name:MAXON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:MARIE
Other - Last Name:SCARAMUZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6811 WOODCHUCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9746
Mailing Address - Country:US
Mailing Address - Phone:908-812-6465
Mailing Address - Fax:
Practice Address - Street 1:720 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1702
Practice Address - Country:US
Practice Address - Phone:315-425-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2498152W00000X
FL5434152W00000X
CO0003751152W00000X
NYTUV008341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist