Healthcare Provider Details

I. General information

NPI: 1760682942
Provider Name (Legal Business Name): WERONIKA ANNA MICULA-GONDEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 CEDAR LN
COLUMBIA MD
21044-2912
US

IV. Provider business mailing address

6501 N CHARLES ST
BALTIMORE MD
21204-6819
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-7910
  • Fax: 410-740-7517
Mailing address:
  • Phone: 410-938-3000
  • Fax: 410-938-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberD76792
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD039527
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD039527
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD76792
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: