Healthcare Provider Details

I. General information

NPI: 1952398950
Provider Name (Legal Business Name): LARA L DIMICK-SANTOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PKWY
ANNAPOLIS MD
21401-3280
US

IV. Provider business mailing address

PO BOX 64834
BALTIMORE MD
21264-4834
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1000
  • Fax: 443-481-1360
Mailing address:
  • Phone: 443-481-6580
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0063559
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: