Provider Demographics
NPI:1790904001
Name:STILLWAGON, ANGELA (DO)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:STILLWAGON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2364
Mailing Address - Country:US
Mailing Address - Phone:513-475-8730
Mailing Address - Fax:513-475-8033
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8730
Practice Address - Fax:513-475-8033
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN58001737208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200957550Medicaid
INM400071492OtherGROUP MEMBER PTAN
INM400071492OtherGROUP MEMBER PTAN