Healthcare Provider Details

I. General information

NPI: 1063493609
Provider Name (Legal Business Name): CASPER EZRA CLINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 9TH ST
FREDERICK MD
21701-4541
US

IV. Provider business mailing address

300 W 9TH ST
FREDERICK MD
21701-4541
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-8119
  • Fax: 301-696-0985
Mailing address:
  • Phone: 301-662-8119
  • Fax: 301-696-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD16428
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: