Healthcare Provider Details

I. General information

NPI: 1740634880
Provider Name (Legal Business Name): CARMEN ELENA CERVANTES PACURUCU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARMEN ELENA CERVANTES PACURUCU MD

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date: 11/28/2016
Reactivation Date: 12/16/2016

III. Provider practice location address

1830 E. MONUMENT ST. 4TH FLOOR / SUITE 416
BALTIMORE MD
21287
US

IV. Provider business mailing address

6201 GREENLEIGH AVE 2ND FLOOR
MIDDLE RIVER MD
21220
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD90474
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD90474
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: