Healthcare Provider Details

I. General information

NPI: 1326080193
Provider Name (Legal Business Name): MARIA L JISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA LEONOR GONZALES JISON

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 CONNECTICUT AVE SUITE 206
KENSINGTON MD
20895-3910
US

IV. Provider business mailing address

11006 VEIRS MILL RD PMB 261
WHEATON MD
20902-2582
US

V. Phone/Fax

Practice location:
  • Phone: 888-340-3330
  • Fax: 240-489-6262
Mailing address:
  • Phone: 888-340-3330
  • Fax: 240-489-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101237603
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD0054450
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberD0054450
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number010237603
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: