Healthcare Provider Details

I. General information

NPI: 1801806070
Provider Name (Legal Business Name): DARRYL C. DEVIVO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 FORT WASHINGTON AVE
NEW YORK NY
10032-3722
US

IV. Provider business mailing address

710 W 168TH ST
NEW YORK NY
10032-3726
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5244
  • Fax: 212-305-7036
Mailing address:
  • Phone: 212-305-5244
  • Fax: 212-305-7036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number136945
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: