Provider Demographics
NPI:1306919097
Name:CHANGO-HOLT, ANGELA MARIE (OD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:CHANGO-HOLT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 RALEIGH RD
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-7079
Mailing Address - Country:US
Mailing Address - Phone:717-657-7792
Mailing Address - Fax:717-657-1423
Practice Address - Street 1:ROUTE 22 & COLONIAL ROAD
Practice Address - Street 2:COLONIAL PARK MALL
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-6234
Practice Address - Country:US
Practice Address - Phone:717-657-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA063327Q1AMedicare ID - Type Unspecified
PAU92207Medicare UPIN