Provider Demographics
NPI:1265480172
Name:GERGUIS, ANGELA SELLERS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:SELLERS
Last Name:GERGUIS
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 1:1203 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0850
Mailing Address - Country:US
Mailing Address - Phone:912-871-7890
Mailing Address - Fax:912-871-7898
Practice Address - Street 1:1203 BRAMPTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0850
Practice Address - Country:US
Practice Address - Phone:912-871-7890
Practice Address - Fax:912-871-7898
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047261207Q00000X
GA47261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBTHFMedicaid
GA00833951BMedicaid
GA00833951BMedicaid