Provider Demographics
NPI:1922009034
Name:MARTIN, ANGELIQUE (RD, CDN)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 RALPH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5300
Mailing Address - Country:US
Mailing Address - Phone:646-752-9842
Mailing Address - Fax:
Practice Address - Street 1:2035 RALPH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5300
Practice Address - Country:US
Practice Address - Phone:646-752-9842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189769132700000X
NY005623-1133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY155835POtherHIP
NY182870OtherELDERPLAN
NYP3105474OtherOXFORD
NYP3105806OtherOXFORD
NY2579429OtherUNITED HEALTHCARE
NY9607811OtherCIGNA
NY8099800OtherGHI
NY9607811OtherCIGNA