Provider Demographics
NPI:1578641346
Name:KING-ANGELL, JOAN LUCILE (MD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:LUCILE
Last Name:KING-ANGELL
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 1:2344 - 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710
Mailing Address - Country:US
Mailing Address - Phone:510-981-3203
Mailing Address - Fax:510-981-4191
Practice Address - Street 1:3260 SACRAMENTO ST
Practice Address - Street 2:OVER 60 CLINIC
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702
Practice Address - Country:US
Practice Address - Phone:510-274-8996
Practice Address - Fax:510-981-4191
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58410207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G584100Medicaid
F16601Medicare UPIN
CA00G584100Medicaid