Basic Information
| Provider Information | |||||||||
| NPI: | 1477573269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANGULO | ||||||||
| FirstName: | MORIS | ||||||||
| MiddleName: | ALEJANDRO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 611 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632532 | ||||||||
| FaxNumber: | 5166632233 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633090 | ||||||||
| FaxNumber: | 5166633070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 159613 | NY | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 2080P0205X | 159613 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 01244435 | 05 | NY | MEDICAID |