Provider Demographics
NPI:1790195907
Name:STALLER, ANGIE LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:LEIGH
Last Name:STALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:LEIGH
Other - Last Name:BUSCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5735 CHELTENHAM DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-2929
Mailing Address - Country:US
Mailing Address - Phone:281-686-8696
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 420
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3007
Practice Address - Country:US
Practice Address - Phone:832-325-7280
Practice Address - Fax:713-512-7104
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS1284208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program