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General NPI Number Information
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NPI Number | 1063237360
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Entity Type | Organization
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Legal Business Name | ANGEL LAKE, MD
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Dates
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Enumeration Date | 11/20/2024
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Last Update Date | 02/13/2025
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Provider Practice Location Address
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Address Line | 4007 ESTATE DIAMOND RUBY
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City | CHRISTIANSTED
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State | VI
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Zip | 00820-4435
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Country | US
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Telephone | 340-332-3665
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Fax | 210-682-9509
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Provider Business Mailing Address
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Address Line | PO BOX 1051
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City | CHRISTIANSTED
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State | VI
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Zip | 00821-1051
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Country | US
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Telephone | 340-332-3665
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Fax | 210-682-9509
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. ANGEL LAKE
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Credential | MD
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Telephone | 340-332-3665
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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