Healthcare Provider Details

I. General information

NPI: 1487588935
Provider Name (Legal Business Name): SIARA PRIDGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 HARFORD RD
BALTIMORE MD
21214-3205
US

IV. Provider business mailing address

4709 HARFORD RD # 86
BALTIMORE MD
21214-3205
US

V. Phone/Fax

Practice location:
  • Phone: 410-240-0404
  • Fax:
Mailing address:
  • Phone: 410-240-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number25-CPT1500
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: