Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 208D00000X | General Practice | | D19954 | MARYLAND | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 0050694000 | MEDICAID | WEST VIRGINIA | |
| 2 | 41665301 | OTHER | MARYLAND | CAREFIRST BC BS |
| 3 | E458 0015 | OTHER | DISTRICT OF COLUMBIA | BLUE CHOICE - HT. CLUB |
| 4 | B69586 | MEDICARE UPIN | MARYLAND | |
| 5 | LU39HU 416653 02 | OTHER | MARYLAND | CAREFIRST BC BS - HT.CLUB |
| 6 | K029 0003 | OTHER | DISTRICT OF COLUMBIA | BLUE CHOICE DC |
| 7 | 672S | MEDICARE PIN | MARYLAND | |
