Provider Demographics
NPI:1568686814
Name:ANGELO, TIMOTHY PHEASANT (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PHEASANT
Last Name:ANGELO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JOHN-TIMOTHY
Other - Middle Name:PHEASANT
Other - Last Name:ANGELO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:903 EMBARCADERO DR
Mailing Address - Street 2:STE 4
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-4098
Mailing Address - Country:US
Mailing Address - Phone:916-933-9870
Mailing Address - Fax:916-933-3540
Practice Address - Street 1:903 EMBARCADERO DR
Practice Address - Street 2:SUITE 3
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-4098
Practice Address - Country:US
Practice Address - Phone:916-933-9870
Practice Address - Fax:916-933-2708
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30036111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0300360Medicare PIN