Healthcare Provider Details

I. General information

NPI: 1700770088
Provider Name (Legal Business Name): BLADIMIR HENRIQUEZ LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

206 HUTTON ST
GAITHERSBURG MD
20877-2056
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-0501
  • Fax:
Mailing address:
  • Phone: 410-706-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR231781
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: