Basic Information
| Provider Information | |||||||||
| NPI: | 1306157078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECHEVERRIA | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D., M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2350 MIAMI VALLEY DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374388640 | ||||||||
| FaxNumber: | 9374388615 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 MIAMI VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374388640 | ||||||||
| FaxNumber: | 9374388615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME129595 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 35.140245 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | R72234 | AZ | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0412130 | 05 | OH | MEDICAID |