Provider Demographics
NPI:1386604650
Name:DEANGELO, NICHOLAS A (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:DEANGELO
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 1:541 MELDON RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7103
Mailing Address - Country:US
Mailing Address - Phone:717-557-5926
Mailing Address - Fax:
Practice Address - Street 1:541 MELDON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:717-557-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0059778208VP0014X
GA075048207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD658LN688Medicare PIN
PAG71343Medicare UPIN
MDP00303286Medicare PIN
PAG71343Medicare UPIN