Provider Demographics
NPI:1881601813
Name:JO, ANGELA MI KYUNG (MD, MSHS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MI KYUNG
Last Name:JO
Suffix:
Gender:F
Credentials:MD, MSHS
Other - Prefix:
Other - First Name:MI KYUNG
Other - Middle Name:
Other - Last Name:JO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MSHS
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:8200 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2408
Practice Address - Country:US
Practice Address - Phone:505-272-5885
Practice Address - Fax:505-272-6308
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I30407Medicare UPIN