Provider Demographics
NPI:1245244854
Name:DEARINGER, ANGELA TACKETT (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:TACKETT
Last Name:DEARINGER
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 1:2333 ALUMNI PARK PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4012
Mailing Address - Country:US
Mailing Address - Phone:859-218-5677
Mailing Address - Fax:859-257-7899
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64110059Medicaid
0929199Medicare ID - Type Unspecified
KY64110059Medicaid