Healthcare Provider Details

I. General information

NPI: 1316090855
Provider Name (Legal Business Name): EBENEZER NETTEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 HOSPITAL DRIVE SUITE 103
CLINTON MD
20735
US

IV. Provider business mailing address

10401 HOSPITAL DRIVE SUITE 103
CLINTON MD
20735
US

V. Phone/Fax

Practice location:
  • Phone: 301-932-8580
  • Fax:
Mailing address:
  • Phone: 301-856-0334
  • Fax: 301-856-0709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberD0036594
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: