Healthcare Provider Details

I. General information

NPI: 1811428964
Provider Name (Legal Business Name): ANGELO ANTHONY CILIBERTI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 DUTCHMANS LN STE 208
LOUISVILLE KY
40207-4723
US

IV. Provider business mailing address

3991 DUTCHMANS LN STE 208
LOUISVILLE KY
40207-4723
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-6061
  • Fax: 502-899-6127
Mailing address:
  • Phone: 502-899-6061
  • Fax: 502-899-6127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number56690
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.151848
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.070055
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number036.151848
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: