Provider Demographics
NPI:1053353144
Name:ANGELES, FERNANDO SAN MIGUEL
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:SAN MIGUEL
Last Name:ANGELES
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:FERNANDO
Other - Middle Name:SAN MIGUEL
Other - Last Name:ANGELES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8808 RACQUET CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-2836
Mailing Address - Country:US
Mailing Address - Phone:817-861-3147
Mailing Address - Fax:
Practice Address - Street 1:11803 S INTERSTATE 35W
Practice Address - Street 2:SUITE 354
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-0000
Practice Address - Country:US
Practice Address - Phone:817-293-9140
Practice Address - Fax:817-293-2392
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032272902Medicaid
TXTXB140518Medicare PIN