Healthcare Provider Details

I. General information

NPI: 1538554266
Provider Name (Legal Business Name): KENNETH JOHN TAUBENSLAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 07/07/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W REDWOOD ST STE 470
BALTIMORE MD
21201-7009
US

IV. Provider business mailing address

419 W REDWOOD ST STE 470
BALTIMORE MD
21201-7009
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1111
  • Fax: 410-328-6503
Mailing address:
  • Phone: 667-214-1111
  • Fax: 410-328-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0091402
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberD0091402
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: