Healthcare Provider Details

I. General information

NPI: 1972099083
Provider Name (Legal Business Name): EMERSON CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 KENNEDY ST NW STE 207
WASHINGTON DC
20011
US

IV. Provider business mailing address

508 KENNEDY ST NW STE 306
WASHINGTON DC
20011-3010
US

V. Phone/Fax

Practice location:
  • Phone: 202-239-0777
  • Fax: 202-849-8814
Mailing address:
  • Phone: 202-239-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FABIAN SANDOVAL
Title or Position: CEO
Credential: MD
Phone: 202-239-0777