Healthcare Provider Details

I. General information

NPI: 1972512408
Provider Name (Legal Business Name): KWASI A DEBRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 ANNAPOLIS RD STE 123
GLENN DALE MD
20769-9182
US

IV. Provider business mailing address

12200 ANNAPOLIS RD STE 123
GLENN DALE MD
20769-9182
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-9495
  • Fax: 301-552-9743
Mailing address:
  • Phone: 301-552-9495
  • Fax: 301-552-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD20163
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberD0040683
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: