Healthcare Provider Details

I. General information

NPI: 1750370342
Provider Name (Legal Business Name): ILEANA SHOWALTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SAINT PAUL PL SUITE 612
BALTIMORE MD
21202-2102
US

IV. Provider business mailing address

501 SAINT PAUL PL APT. 1002
BALTIMORE MD
21202-2270
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-6126
  • Fax: 410-539-3418
Mailing address:
  • Phone: 410-837-8286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0061870
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: