Healthcare Provider Details

I. General information

NPI: 1881642569
Provider Name (Legal Business Name): ANGELA G KNESTAUT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 KINGS HIGHWAY
WEST DEPTFORD NJ
08096
US

IV. Provider business mailing address

402 LIPPINCOTT DR
MARLTON NJ
08053-4112
US

V. Phone/Fax

Practice location:
  • Phone: 856-879-2887
  • Fax: 856-879-2855
Mailing address:
  • Phone: 856-782-3300
  • Fax: 856-504-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB06561600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: