Healthcare Provider Details

I. General information

NPI: 1821612466
Provider Name (Legal Business Name): MUSA MUSA MIVANYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 12/18/2023
Certification Date: 11/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 PARK HEIGHTS AVE
BALTIMORE MD
21215-6725
US

IV. Provider business mailing address

4340 PARK HEIGHTS AVE
BALTIMORE MD
21215-6725
US

V. Phone/Fax

Practice location:
  • Phone: 410-542-8130
  • Fax:
Mailing address:
  • Phone: 410-542-8130
  • Fax: 410-542-1826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0097898
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: