Healthcare Provider Details

I. General information

NPI: 1003953290
Provider Name (Legal Business Name): MICHELLE ZIKUSOKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BOULEVARD RMB SUITE 206
BALTIMORE MD
21239
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD RMB SUITE 206
BALTIMORE MD
21239-2945
US

V. Phone/Fax

Practice location:
  • Phone: 443-444-5613
  • Fax:
Mailing address:
  • Phone: 443-444-5613
  • Fax: 443-444-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0069504
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: