Healthcare Provider Details

I. General information

NPI: 1114312758
Provider Name (Legal Business Name): IDONGESIT IHEANYICHUKWU ATTANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCANTILE LANE
LARGO MD
20774
US

IV. Provider business mailing address

2101 E JEFFERSON ST STE 6W
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 301-618-5500
  • Fax:
Mailing address:
  • Phone: 301-816-5853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD84615
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: