Provider Demographics
NPI:1962494294
Name:WINGFIELD, ANGELA BOOTH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:BOOTH
Last Name:WINGFIELD
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 1:11295 E TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4197
Mailing Address - Country:US
Mailing Address - Phone:228-864-3300
Mailing Address - Fax:
Practice Address - Street 1:11295 E TAYLOR RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4197
Practice Address - Country:US
Practice Address - Phone:228-864-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024878207NS0135X
MS1731207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
25D1013637OtherCLIA
MS00874879Medicaid
25D1013637OtherCLIA
MS070000100Medicare PIN