Provider Demographics
NPI:1164412169
Name:GONZALEZ-PRADO, ANGELES (MD)
Entity Type:Individual
Prefix:
First Name:ANGELES
Middle Name:
Last Name:GONZALEZ-PRADO
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 1:315 NEW ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 E 21ST ST
Practice Address - Street 2:SUITE 400
Practice Address - City:NORTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18067-1259
Practice Address - Country:US
Practice Address - Phone:610-262-1519
Practice Address - Fax:610-262-7125
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062524L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016576820003Medicaid
P002678OtherGATEWAY
50055254OtherCBC
0514959000OtherIBC
260592OtherHIGHMARK BLUE SHIELD
P002678OtherGATEWAY
PAP00261596Medicare PIN
PA054847E6FMedicare PIN