Healthcare Provider Details

I. General information

NPI: 1275060949
Provider Name (Legal Business Name): BISRAT NIGUSSIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GARRETT AVE
LA PLATA MD
20646-5960
US

IV. Provider business mailing address

900 ELKRIDGE LANDING RD FL 2
LINTHICUM MD
21090-2924
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA12432200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD01054138
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: