Provider Demographics
NPI:1598787749
Name:ICEBERG, ANGELA DENA (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:DENA
Last Name:ICEBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 COREY LN
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9707
Mailing Address - Country:US
Mailing Address - Phone:248-884-4246
Mailing Address - Fax:
Practice Address - Street 1:31815 SOUTHFIELD RD STE 12
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:248-645-2220
Practice Address - Fax:877-547-8277
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5330000481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1300001OtherMEDICARE PTAN
MIU32638Medicare UPIN