Provider Demographics
NPI:1124386560
Name:TEBALDI, ANGELA DANIELLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DANIELLE
Last Name:TEBALDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:MAURER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:81 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2771
Mailing Address - Country:US
Mailing Address - Phone:207-319-6112
Mailing Address - Fax:
Practice Address - Street 1:1721 E 19TH AVE
Practice Address - Street 2:#520
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1251
Practice Address - Country:US
Practice Address - Phone:303-839-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1095213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty