Provider Demographics
NPI:1194808030
Name:SUBAUSTE, ANGELA R (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:SUBAUSTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:HYPERTENSION
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-5525
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5525
Practice Address - Fax:601-984-6439
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080359207R00000X, 207RE0101X
MS22041207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4641855Medicaid
MS09232094Medicaid
MS302I463412Medicare PIN
MII17163Medicare UPIN
MS09232094Medicaid