Provider Demographics
NPI:1578575940
Name:ELCOCK-VENGEN, JULIA ANGELA (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:ANGELA
Last Name:ELCOCK-VENGEN
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 1:1401 S 31ST ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3506
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:1401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-3506
Practice Address - Country:US
Practice Address - Phone:215-755-7700
Practice Address - Fax:215-755-3177
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062119L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017329470001Medicaid
PA0017329470001Medicaid
PAF29499Medicare UPIN