Basic Information
| Provider Information | |||||||||
| NPI: | 1144696576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALCARAZ-ANGULO | ||||||||
| FirstName: | FABIAN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 LONDONDERRY RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 LONDONDERRY RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2015 | ||||||||
| LastUpdateDate: | 01/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD461677 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 103320928 | 05 | PA | MEDICAID |