Provider Demographics
NPI:1437284130
Name:ANDERSON, ANGELIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:ANDERSON
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 1:33 W 127TH ST
Mailing Address - Street 2:#1G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3830
Mailing Address - Country:US
Mailing Address - Phone:917-312-3381
Mailing Address - Fax:
Practice Address - Street 1:4290 BROADWAY
Practice Address - Street 2:SUITE 2S
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3732
Practice Address - Country:US
Practice Address - Phone:212-781-5075
Practice Address - Fax:212-781-5329
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216903173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH85143Medicare UPIN