Provider Demographics
NPI:1104023134
Name:ANGELA D SELF MD
Entity Type:Organization
Organization Name:ANGELA D SELF MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-788-1059
Mailing Address - Street 1:5409 DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-6827
Mailing Address - Country:US
Mailing Address - Phone:817-788-1059
Mailing Address - Fax:817-581-1065
Practice Address - Street 1:5409 DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6827
Practice Address - Country:US
Practice Address - Phone:817-788-1059
Practice Address - Fax:817-581-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0043KLOtherBLUE CROSS BLUE SHIELD
TX0043KLOtherBLUE CROSS BLUE SHIELD
TXH81848Medicare UPIN
TXP00048905Medicare ID - Type UnspecifiedRAILROAD MEDICARE