Basic Information
| Provider Information | |||||||||
| NPI: | 1497896799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEROPOULOS | ||||||||
| FirstName: | ANGELO | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 HILLSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940256537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508541833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1141 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936623241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598916244 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A048718 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A487180 | 05 | CA | MEDICAID |