Healthcare Provider Details

I. General information

NPI: 1346460698
Provider Name (Legal Business Name): CAROLINE DELCETA BLACK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date: 05/04/2023
Reactivation Date: 05/23/2023

III. Provider practice location address

NATIONAL NAVAL MEDICAL CENTER ROCKVILLE PIKE
BETHESDA MD
20850
US

IV. Provider business mailing address

13116 ARDENNES AVE
ROCKVILLE MD
20851-2332
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4880
  • Fax:
Mailing address:
  • Phone: 301-540-1886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number17660
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: