Healthcare Provider Details

I. General information

NPI: 1003556242
Provider Name (Legal Business Name): JULIAN ALEXANDER ANGELES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE STE 2120
MARIETTA GA
30060-1180
US

IV. Provider business mailing address

61 WHITCHER ST NE STE 2120
MARIETTA GA
30060-1180
US

V. Phone/Fax

Practice location:
  • Phone: 770-423-0595
  • Fax: 678-391-5055
Mailing address:
  • Phone: 770-423-0595
  • Fax: 678-391-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number206
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: