Provider Demographics
NPI:1750321576
Name:DEBORD HENRIKSEN, ANGELA A (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:A
Last Name:DEBORD HENRIKSEN
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:SUITE 318
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6914
Practice Address - Country:US
Practice Address - Phone:317-217-2600
Practice Address - Fax:317-217-2606
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050868A207R00000X
IN01050868207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200338010Medicaid
INP00844459OtherRAILROAD MEDICARE PTAN
IN223760IMedicare PIN
IN221900DMedicare PIN
IN149170JMedicare PIN
INP00844459OtherRAILROAD MEDICARE PTAN
IN264430BBBMedicare PIN