Provider Demographics
NPI:1770188252
Name:ANGELA I INGENDAAY M D PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ANGELA I INGENDAAY M D PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:I
Authorized Official - Last Name:INGENDAAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-559-1342
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:OREGON HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95962-0856
Mailing Address - Country:US
Mailing Address - Phone:530-559-1342
Mailing Address - Fax:530-692-7020
Practice Address - Street 1:150 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6576
Practice Address - Country:US
Practice Address - Phone:530-559-1342
Practice Address - Fax:530-692-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty