1295112977 NPI number — DR. NICHOLAS WILLIAM DEANGELIS M.D.

Table of content: DR. NICHOLAS WILLIAM DEANGELIS M.D. (NPI 1295112977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295112977 NPI number — DR. NICHOLAS WILLIAM DEANGELIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEANGELIS
Provider First Name:
NICHOLAS
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1295112977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3530 STEFFISBURG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37211-8358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-529-6034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LAURA LIBERMAN MD PA
Provider Second Line Business Practice Location Address:
1130 BALTIMORE BOULEVARD SUITE B
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-876-9680
Provider Business Practice Location Address Fax Number:
410-386-0876
Provider Enumeration Date:
04/30/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: D0082683 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 225ILIDD , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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