Provider Demographics
NPI:1124557442
Name:KARGENIAN, ANGELA DAWN (OD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:KARGENIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:DAWN
Other - Last Name:RATLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6193
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86402-6193
Mailing Address - Country:US
Mailing Address - Phone:231-303-0635
Mailing Address - Fax:
Practice Address - Street 1:220 N MCKEMY AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2654
Practice Address - Country:US
Practice Address - Phone:480-961-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist