Provider Demographics
NPI:1689679391
Name:WHITESELL, ANGIE J (MD)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:J
Last Name:WHITESELL
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 1:1307 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-1129
Mailing Address - Country:US
Mailing Address - Phone:417-232-4560
Mailing Address - Fax:417-232-4561
Practice Address - Street 1:1307 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOCKWOOD
Practice Address - State:MO
Practice Address - Zip Code:65682
Practice Address - Country:US
Practice Address - Phone:417-232-4560
Practice Address - Fax:417-232-4611
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014018207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
MO207274408Medicaid
MO132300031Medicare PIN
MOH90269Medicare UPIN