Healthcare Provider Details

I. General information

NPI: 1750693503
Provider Name (Legal Business Name): MD LASER MEDICINE AND SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 02/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 MINSTREL WAY SUITE 103
COLUMBIA MD
21045-5248
US

IV. Provider business mailing address

7120 MINSTREL WAY SUITE 103
COLUMBIA MD
21045-5248
US

V. Phone/Fax

Practice location:
  • Phone: 443-283-0600
  • Fax: 443-283-0399
Mailing address:
  • Phone: 443-283-0600
  • Fax: 443-283-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLEMENT S BANDA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 443-283-0600