Healthcare Provider Details

I. General information

NPI: 1255313136
Provider Name (Legal Business Name): JEFFREY DUNMAN MEWBORNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE STREET
BALTIMORE MD
21264-5758
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5000
  • Fax:
Mailing address:
  • Phone: 109-336-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number9601003
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberD96853
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: