Provider Demographics
NPI:1629076450
Name:DEANGELIS, CHRISTOPHER R (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:DEANGELIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25000 HALL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-5112
Mailing Address - Country:US
Mailing Address - Phone:734-676-3373
Mailing Address - Fax:734-676-2014
Practice Address - Street 1:25000 HALL RD
Practice Address - Street 2:STE 1
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-5112
Practice Address - Country:US
Practice Address - Phone:734-676-3373
Practice Address - Fax:734-676-2014
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICD013396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P109110OtherBCN
38-3510876OtherTAX ID#
1172589003OtherCIGNA
5390707OtherAETNA
1158206834OtherBCBS
C8111OtherM-CARE
CD013396OtherSTATE LIC#
P127746OtherCARE CHOICES
110218319OtherRAILROAD
110218319OtherRAILROAD
C8111OtherM-CARE
H14127Medicare UPIN
0M99720Medicare ID - Type Unspecified