Healthcare Provider Details

I. General information

NPI: 1346990652
Provider Name (Legal Business Name): JOHN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 THOMAS JOHNSON DR STE 100
FREDERICK MD
21702-4509
US

IV. Provider business mailing address

141 THOMAS JOHNSON DR STE 100
FREDERICK MD
21702-4509
US

V. Phone/Fax

Practice location:
  • Phone: 301-228-9123
  • Fax:
Mailing address:
  • Phone: 240-696-3927
  • Fax: 301-228-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH0102911
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH0102911
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: