Basic Information
| Provider Information | |||||||||
| NPI: | 1578641346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING-ANGELL | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | LUCILE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2344 - 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109813203 | ||||||||
| FaxNumber: | 5109814191 | ||||||||
| Practice Location | |||||||||
| Address1: | 3260 SACRAMENTO ST | ||||||||
| Address2: | OVER 60 CLINIC | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102748996 | ||||||||
| FaxNumber: | 5109814191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | G58410 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G584100 | 05 | CA | MEDICAID |