Provider Demographics
NPI:1548252125
Name:ANGELITO HENRITO K JAO MD PC
Entity type:Organization
Organization Name:ANGELITO HENRITO K JAO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELITO
Authorized Official - Middle Name:HENRITO K
Authorized Official - Last Name:JAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-267-4711
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1089
Mailing Address - Country:US
Mailing Address - Phone:770-267-4711
Mailing Address - Fax:770-267-7320
Practice Address - Street 1:333 ALCOVY ST
Practice Address - Street 2:STE 3
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2180
Practice Address - Country:US
Practice Address - Phone:770-267-4711
Practice Address - Fax:770-267-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
905606OtherSOUTHCARE
GA52237698001OtherBLUE CROSS/BLUE SHIELD
GA00349027AMedicaid
452392064AMedicare ID - Type Unspecified
905606OtherSOUTHCARE