Provider Demographics
NPI:1588621551
Name:HART, ANGELIQUE MARIE (MD)
Entity type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:HART
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 1:1530 BISHOPS LODGE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-0005
Mailing Address - Country:US
Mailing Address - Phone:505-983-1293
Mailing Address - Fax:505-467-8309
Practice Address - Street 1:1530 BISHOPS LODGE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-0005
Practice Address - Country:US
Practice Address - Phone:505-983-1293
Practice Address - Fax:505-467-8309
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64653207LP2900X
NMMD2006-0057207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30924049Medicaid
NM30924049Medicaid