Provider Demographics
NPI:1497762629
Name:ASOM, ANGELA E (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:E
Last Name:ASOM
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 1:421 PALOMINO WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1531
Mailing Address - Country:US
Mailing Address - Phone:469-585-7721
Mailing Address - Fax:
Practice Address - Street 1:717 S GREENVILLE AVE
Practice Address - Street 2:STE 104
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-3317
Practice Address - Country:US
Practice Address - Phone:972-396-1900
Practice Address - Fax:972-396-1901
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2023-1277208000000X
NJMA69683208000000X
PAMD058635L208000000X
TXL8604208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001632389Medicaid
NJ7291507Medicaid
TXL8604OtherTX LICENSE
TXL8604OtherTX LICENSE
PA712799Medicare ID - Type Unspecified