Healthcare Provider Details

I. General information

NPI: 1386795573
Provider Name (Legal Business Name): KHONDKER M SHAMSUZZOHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 THOMAS JOHNSON DR SUITE # 215
FREDERICK MD
21702-4397
US

IV. Provider business mailing address

6567 FORSYTHIA ST
SPRINGFIELD VA
22150-1167
US

V. Phone/Fax

Practice location:
  • Phone: 301-668-9988
  • Fax: 301-668-9977
Mailing address:
  • Phone: 703-822-0845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD 0057162
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: