Healthcare Provider Details

I. General information

NPI: 1649229634
Provider Name (Legal Business Name): ENRIQUE DAZA RACINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602B SHIELDS DR
BETHESDA MD
20817-3571
US

IV. Provider business mailing address

5602B SHIELDS DR
BETHESDA MD
20817-3571
US

V. Phone/Fax

Practice location:
  • Phone: 301-897-0044
  • Fax: 301-897-0046
Mailing address:
  • Phone: 301-897-0044
  • Fax: 301-897-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19033
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberBD42181
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD42181
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: