Healthcare Provider Details

I. General information

NPI: 1356729040
Provider Name (Legal Business Name): EDILBERTO ATIENZA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 WILKENS AVE
BALTIMORE MD
21229
US

IV. Provider business mailing address

3407 WILKENS AVE
BALTIMORE MD
21229-5072
US

V. Phone/Fax

Practice location:
  • Phone: 240-804-5368
  • Fax:
Mailing address:
  • Phone: 240-804-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberD0084921
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: