Provider Demographics
NPI:1831119619
Name:DE LOS ANGELES, SERVANDO (MD)
Entity type:Individual
Prefix:
First Name:SERVANDO
Middle Name:
Last Name:DE LOS ANGELES
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 1:5 PERRYRIDGE RD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4608
Mailing Address - Country:US
Mailing Address - Phone:203-863-3637
Mailing Address - Fax:203-863-3821
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:203-863-3637
Practice Address - Fax:203-863-3821
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031177207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT950000592Medicare ID - Type Unspecified
E48805Medicare UPIN