Provider Demographics
NPI:1588734677
Name:ANGELO, CHERYL ANN (OD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:ANGELO
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 1:813 E GATE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1238
Mailing Address - Country:US
Mailing Address - Phone:856-642-7600
Mailing Address - Fax:856-608-0501
Practice Address - Street 1:813 E GATE DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1238
Practice Address - Country:US
Practice Address - Phone:856-642-7600
Practice Address - Fax:856-608-0501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1350803Medicaid
NJ1350803Medicaid
NJ632250Medicare ID - Type Unspecified