Provider Demographics
NPI:1679641161
Name:DEWEESE, ANGELA FAYE (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:FAYE
Last Name:DEWEESE
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 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-429-1818
Mailing Address - Fax:812-426-9564
Practice Address - Street 1:545 S BOEHNE CAMP RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-3703
Practice Address - Country:US
Practice Address - Phone:812-429-1818
Practice Address - Fax:812-426-9564
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047130A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200116780Medicaid
KY64075823OtherKY MEDICAID
IN000000318862OtherANTHEM
IN200116780Medicaid
INP00222137Medicare PIN
IN257900BBBMedicare PIN
ING59039Medicare UPIN