Healthcare Provider Details

I. General information

NPI: 1285977272
Provider Name (Legal Business Name): PHILIP DUDKIN SACKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CATON AVE
BALTIMORE MD
21229-5201
US

IV. Provider business mailing address

1407 PROVIDENCE RD
TOWSON MD
21286-1521
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-2011
  • Fax:
Mailing address:
  • Phone: 254-681-3701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0081551
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: