Healthcare Provider Details

I. General information

NPI: 1457873325
Provider Name (Legal Business Name): CLINTON FIBROID & VASCULAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 PISCATAWAY RD STE 240
CLINTON MD
20735-2578
US

IV. Provider business mailing address

9131 PISCATAWAY RD STE 240
CLINTON MD
20735-2578
US

V. Phone/Fax

Practice location:
  • Phone: 240-244-2302
  • Fax: 410-975-4645
Mailing address:
  • Phone: 240-244-2302
  • Fax: 410-975-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD0063972
License Number StateMD

VIII. Authorized Official

Name: DR. NORDINE GAUGAU
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 240-244-2302