Basic Information
| Provider Information | |||||||||
| NPI: | 1114129913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIDDER | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1821 HILLANDALE RD | ||||||||
| Address2: | #24-A | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277052659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193834355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1821 HILLANDALE RD | ||||||||
| Address2: | #24-A | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277052659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193834355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 10/28/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16497 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2015-00568 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.