Healthcare Provider Details

I. General information

NPI: 1508839077
Provider Name (Legal Business Name): DIANA FERTSCH MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 MERRITT BLVD DUNDALK PEDIATRIC ASSOCIATES
DUNDALK MD
21222-2122
US

IV. Provider business mailing address

1792 MERRITT BLVD DUNDALK PEDIATRIC ASSOCIATES
DUNDALK MD
21222
US

V. Phone/Fax

Practice location:
  • Phone: 410-284-1133
  • Fax: 410-284-3371
Mailing address:
  • Phone: 410-284-1133
  • Fax: 410-284-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD45937
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: