Healthcare Provider Details

I. General information

NPI: 1316947617
Provider Name (Legal Business Name): GEOFFREY G MOUNTVARNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW EMERGENCY DEPT ADMIN OFFICE
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

12710 WOODBRIDGE CT
MITCHELLVILLE MD
20721-4243
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-1121
  • Fax:
Mailing address:
  • Phone: 202-865-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD0054648
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: