Provider Demographics
NPI:1619265642
Name:OSMOLAK, ANGELA M (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:OSMOLAK
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:PO BOX 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-216-1638
Practice Address - Street 1:8303 DODGE ST STE 304
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-354-5048
Practice Address - Fax:402-354-2585
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30679207YX0007X
OK31953207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026485711Medicaid
NE10025044400Medicaid
IA1619265642Medicaid