Provider Demographics
NPI:1710448949
Name:GOENAWAN, ANGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:
Last Name:GOENAWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WELLNESS WAY
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-4364
Mailing Address - Country:US
Mailing Address - Phone:302-422-3311
Mailing Address - Fax:
Practice Address - Street 1:100 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-4364
Practice Address - Country:US
Practice Address - Phone:302-422-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2024-02-01
Deactivation Date:2019-11-04
Deactivation Code:
Reactivation Date:2019-11-22
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEC1-0025080207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program