Provider Demographics
NPI:1699284661
Name:RESTIVO, ANGELA MARIA (LMT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIA
Last Name:RESTIVO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6369
Mailing Address - Country:US
Mailing Address - Phone:443-257-3085
Mailing Address - Fax:
Practice Address - Street 1:2180 A1A S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6591
Practice Address - Country:US
Practice Address - Phone:443-257-3085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA85843204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine