Healthcare Provider Details

I. General information

NPI: 1326208216
Provider Name (Legal Business Name): DEVITO INTERNAL MEDICINE AND PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WHITE RD SUITE 205
LITTLE SILVER NJ
07739-1166
US

IV. Provider business mailing address

180 WHITE ROAD SUITE 205
LITTLE SILVER NJ
07739
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone: 111-111-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08232300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA08232300
License Number StateNJ

VIII. Authorized Official

Name: DR. MARC JOSEPH DEVITO
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 111-111-1111