Healthcare Provider Details

I. General information

NPI: 1932241189
Provider Name (Legal Business Name): MR. VICTOR DEAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING STREET NW
WASHINGTON, DC DC
20010
US

IV. Provider business mailing address

7278 MEADOW WOOD WAY
CLARKSVILLE MD
21029-1517
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-5580
  • Fax:
Mailing address:
  • Phone: 301-490-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 30074
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: