Provider Demographics
NPI:1891930913
Name:ANDERSON, ANGELA JUANITA (MD)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:JUANITA
Last Name:ANDERSON
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 1:2353 MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407
Mailing Address - Country:US
Mailing Address - Phone:219-885-1608
Mailing Address - Fax:219-885-1608
Practice Address - Street 1:2353 MADISON STREET
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407
Practice Address - Country:US
Practice Address - Phone:219-885-1608
Practice Address - Fax:219-885-1608
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037923A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice