1497762629 NPI number — ANGELA E ASOM MD

Table of content: ANGELA E ASOM MD (NPI 1497762629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497762629 NPI number — ANGELA E ASOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASOM
Provider First Name:
ANGELA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497762629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 PALOMINO WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75069-1531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-585-7721
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 S GREENVILLE AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75002-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-396-1900
Provider Business Practice Location Address Fax Number:
972-396-1901
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD2023-1277 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: MA69683 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: MD058635L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: L8604 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001632389 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7291507 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: L8604 . This is a "TX LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".