Provider Demographics
NPI:1396060794
Name:KORIAKOS, ANGIE (DO)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:KORIAKOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 W CAMPBELL RD STE 410
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3636
Mailing Address - Country:US
Mailing Address - Phone:972-469-3376
Mailing Address - Fax:972-469-3288
Practice Address - Street 1:399 W CAMPBELL RD STE 410
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3636
Practice Address - Country:US
Practice Address - Phone:972-469-3376
Practice Address - Fax:972-469-3288
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A12095207N00000X
TXP3746207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program