Provider Demographics
NPI:1992785836
Name:FOX-PUTNAM, ANGELA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:MARIE
Last Name:FOX-PUTNAM
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 1:612 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1653
Mailing Address - Country:US
Mailing Address - Phone:704-822-0099
Mailing Address - Fax:704-822-0077
Practice Address - Street 1:612 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1653
Practice Address - Country:US
Practice Address - Phone:704-822-0099
Practice Address - Fax:704-822-0077
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890928GMedicaid
NC4622OtherDAVIS VISION
NC12304OtherSPECTERA
NCOP069OtherEYEMED
NC0928GOtherBLUE CROSS BLUE SHIELD
NC2467474BMedicare PIN
NC0928GOtherBLUE CROSS BLUE SHIELD