Provider Demographics
NPI:1487056404
Name:ANGELO CUSTODE HEALTHCARE
Entity type:Organization
Organization Name:ANGELO CUSTODE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTDS
Authorized Official - Prefix:
Authorized Official - First Name:MILANIA
Authorized Official - Middle Name:ALESSIA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-708-6591
Mailing Address - Street 1:1804 OAKLEY SEAVER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1925
Mailing Address - Country:US
Mailing Address - Phone:352-404-7815
Mailing Address - Fax:352-404-9603
Practice Address - Street 1:1804 OAKLEY SEAVER DR
Practice Address - Street 2:SUITE F
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1925
Practice Address - Country:US
Practice Address - Phone:352-404-7815
Practice Address - Fax:352-404-9603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98015261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277908100Medicaid