Provider Demographics
NPI:1790148591
Name:KNICKERBOCKER, ANGELICA MELILLO (MD, MPH)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MELILLO
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:BIANCA
Other - Last Name:MELILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 NE 36TH ST APT 1409
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-3938
Mailing Address - Country:US
Mailing Address - Phone:347-880-0646
Mailing Address - Fax:
Practice Address - Street 1:1330 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1271
Practice Address - Country:US
Practice Address - Phone:214-941-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4798207V00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program