Healthcare Provider Details

I. General information

NPI: 1932217262
Provider Name (Legal Business Name): THEODORE A GANCAYCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 VARNUM ST NE SUITE 011
WASHINGTON DC
20017
US

IV. Provider business mailing address

2002 MEDICAL PKWY STE 320
ANNAPOLIS MD
21401-7901
US

V. Phone/Fax

Practice location:
  • Phone: 202-529-5200
  • Fax: 202-269-3462
Mailing address:
  • Phone: 410-571-8733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0038919
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD20277
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: