Provider Demographics
NPI:1407919988
Name:ANGELONE, EDGAR O (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:O
Last Name:ANGELONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2650
Mailing Address - Country:US
Mailing Address - Phone:415-457-3451
Mailing Address - Fax:415-457-3819
Practice Address - Street 1:2154 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2650
Practice Address - Country:US
Practice Address - Phone:415-457-3451
Practice Address - Fax:415-457-3819
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13957103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY13957OtherLICENSE NUMBER
CAOPL139570Medicare ID - Type UnspecifiedPROVIDER NUMBER