Healthcare Provider Details

I. General information

NPI: 1790213742
Provider Name (Legal Business Name): POLYCARP EBURUOH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MEDICAL CENTER DR STE 350
LARGO MD
20774-3715
US

IV. Provider business mailing address

11001 ENOCH CT
UPPER MARLBORO MD
20774-2111
US

V. Phone/Fax

Practice location:
  • Phone: 301-655-7114
  • Fax: 240-525-0892
Mailing address:
  • Phone: 301-655-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR194007
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: