Healthcare Provider Details

I. General information

NPI: 1457698706
Provider Name (Legal Business Name): JOSE P NEPOMUCENO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7845 OAKWOOD RD 103
GLEN BURNIE MD
21061-4256
US

IV. Provider business mailing address

7845 OAKWOOD RD 103
GLEN BURNIE MD
21061-4256
US

V. Phone/Fax

Practice location:
  • Phone: 410-768-2048
  • Fax: 410-768-9171
Mailing address:
  • Phone: 410-768-2048
  • Fax: 410-768-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberD16445
License Number StateMD

VIII. Authorized Official

Name: DR. JOSE NEPOMUCENO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-802-1206