Healthcare Provider Details

I. General information

NPI: 1730252594
Provider Name (Legal Business Name): SUZETTE SCIPIO - ETTIENNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZETTE SCIPIO ETTIENNE MD

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 MITCHELLVILLE RD STE 115
BOWIE MD
20716-1385
US

IV. Provider business mailing address

2905 MITCHELLVILLE RD STE 115
BOWIE MD
20716-1385
US

V. Phone/Fax

Practice location:
  • Phone: 301-390-7960
  • Fax: 301-218-2800
Mailing address:
  • Phone: 301-390-7960
  • Fax: 301-218-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0046373
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: