Healthcare Provider Details

I. General information

NPI: 1447259072
Provider Name (Legal Business Name): DEIDRE SPICER MACCANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW PHC
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

PO BOX 631856
BALTIMORE MD
21263-1856
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-8525
  • Fax:
Mailing address:
  • Phone: 202-444-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number33378
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: