Provider Demographics
NPI:1669463279
Name:DEROBERTIS, ANGELA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:DEROBERTIS
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 1:1703 INNOVATION DR STE 100
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-8815
Mailing Address - Country:US
Mailing Address - Phone:717-801-0742
Mailing Address - Fax:
Practice Address - Street 1:1703 INNOVATION DR STE 100
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8815
Practice Address - Country:US
Practice Address - Phone:717-801-0742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI137852085R0001X
MA2233872085R0001X
PAMD066735L2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIP01332041OtherRR MEDICARE
CT008002446Medicaid
MAJ28326OtherBCBS MA
RIP01334694OtherRR MEDICARE
MA470043OtherTUFTS HEALTH PLAN
MA2093723Medicaid
RI8983518OtherCIGNA
RIAK55342Medicaid
MAA38012Medicare ID - Type Unspecified
MA2093723Medicaid
CT008002446Medicaid
MA470043OtherTUFTS HEALTH PLAN