Provider Demographics
NPI:1295112977
Name:DEANGELIS, NICHOLAS WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:DEANGELIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 STEFFISBURG DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-8358
Mailing Address - Country:US
Mailing Address - Phone:480-529-6034
Mailing Address - Fax:
Practice Address - Street 1:LAURA LIBERMAN MD PA
Practice Address - Street 2:1130 BALTIMORE BOULEVARD SUITE B
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157
Practice Address - Country:US
Practice Address - Phone:410-876-9680
Practice Address - Fax:410-386-0876
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0082683208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD225ILIDDMedicaid