Healthcare Provider Details

I. General information

NPI: 1790940997
Provider Name (Legal Business Name): CHESTER Z. HAVERBACK, M.D., CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8218 WISCONSIN AVENUE #320
BETHESDA MD
20814
US

IV. Provider business mailing address

8218 WISCONSIN AVENUE #320
BETHESDA MD
20814
US

V. Phone/Fax

Practice location:
  • Phone: 301-657-4747
  • Fax: 301-657-9065
Mailing address:
  • Phone: 301-657-4747
  • Fax: 301-657-9065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD25318
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD05089
License Number StateMD

VIII. Authorized Official

Name: DR. CHESTER Z. HAVERBACK, M.D.
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 301-657-4747