Healthcare Provider Details

I. General information

NPI: 1679778336
Provider Name (Legal Business Name): M & K YAZDANI P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 08/21/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 SOLOMONS ISLAND RD
HUNTINGTOWN MD
20639
US

IV. Provider business mailing address

2555 SOLOMONS ISLAND RD
HUNTINGTOWN MD
20639-8734
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-1695
  • Fax: 410-535-8684
Mailing address:
  • Phone: 410-535-1695
  • Fax: 410-535-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0017168
License Number StateMD

VIII. Authorized Official

Name: KIOUMARCE YAZDANI
Title or Position: OWNER
Credential: MD
Phone: 410-535-1695