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General NPI Number Information
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NPI Number | 1568697993
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Entity Type | Individual
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Provider Name | CHARLES DOUGLAS ANGEVINE M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/29/2009
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Last Update Date | 05/29/2009
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Provider Practice Location Address
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Address Line | 106 HULBURT RD
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City | FAIRPORT
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State | NY
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Zip | 14450-2464
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Country | US
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Telephone | 585-377-8009
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Fax |
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Provider Business Mailing Address
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Address Line | 106 HULBURT RD
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City | FAIRPORT
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State | NY
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Zip | 14450-2464
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Country | US
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Telephone | 585-377-8009
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 103318-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 16464-020
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License Number State | WI
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