Healthcare Provider Details

I. General information

NPI: 1790176733
Provider Name (Legal Business Name): ALEXANDER ANGELIDIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6633
  • Fax:
Mailing address:
  • Phone: 912-435-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2033
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number76766
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: