MEDICARE: INNOVATIVE PEDIATRICS & MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080B0002X	Pediatric Obesity Medicine Physician
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1568063758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PEDIATRICS & MEDICINE

Provider Business Mailing Address
First Line	:	3921 FERRARA DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906
Country	:	US
Telephone Number	:	301-337-8846
Fax Number	:	301-946-0642

Provider Business Practice Location Address
First Line	:	3921 FERRARA DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906
Country	:	US
Telephone Number	:	301-337-8846
Fax Number	:	301-946-0642

Authorized Official
Title or Position	:	CLINICAN
Name	:	GIFTY AFETA
Credential	:	MD
Telephone Number	:	301-337-8846

Provider Enumeration Date	:	11/04/2020
Last Update Date	:	11/04/2020

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