Provider Demographics
NPI:1457989428
Name:DEVIVO, GABRIEL ANGELO (DO)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ANGELO
Last Name:DEVIVO
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 1:1675 LEAHY ST STE 315A
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5543
Mailing Address - Country:US
Mailing Address - Phone:231-727-5209
Mailing Address - Fax:
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-8779
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151014223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine