Provider Demographics
NPI:1538143599
Name:ANGELO, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:ANGELO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:76409 CROCKETT RD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-3718
Mailing Address - Country:US
Mailing Address - Phone:985-705-3979
Mailing Address - Fax:844-272-9196
Practice Address - Street 1:1970 N HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5364
Practice Address - Country:US
Practice Address - Phone:985-705-9020
Practice Address - Fax:844-272-9196
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014342207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1314650Medicaid
5J034Medicare ID - Type Unspecified
B60267Medicare UPIN