Healthcare Provider Details

I. General information

NPI: 1851515902
Provider Name (Legal Business Name): DEJ MED PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MEMORIAL BLVD W
HAGERSTOWN MD
21740-6219
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: 301-791-8990
Mailing address:
  • Phone: 301-791-7060
  • Fax: 301-791-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHUKUEMEKA OBIDI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-791-7060