Healthcare Provider Details

I. General information

NPI: 1023468212
Provider Name (Legal Business Name): BERTHA O MEJIA DE GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 E KILMER ST
HYATTSVILLE MD
20785-2132
US

IV. Provider business mailing address

7205 E KILMER ST
HYATTSVILLE MD
20785-2132
US

V. Phone/Fax

Practice location:
  • Phone: 240-640-3796
  • Fax:
Mailing address:
  • Phone: 240-640-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-384
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: