Healthcare Provider Details

I. General information

NPI: 1669353504
Provider Name (Legal Business Name): DEJ MED PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13316 MARSH PIKE
HAGERSTOWN MD
21742-2573
US

IV. Provider business mailing address

303 MEMORIAL BLVD W
HAGERSTOWN MD
21740-6219
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-7060
  • Fax:
Mailing address:
  • Phone: 301-791-7060
  • Fax: 301-791-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CHUKWUEMEKA OBIDI
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 301-791-7060