=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043235427
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA JANE DEJULIUS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 02/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 KELSO RD
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-297-2461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2037 OLD FORGE RD
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44240-6744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-678-1746
-----------------------------------------------------
Fax | 330-678-6716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35.071263
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------