Healthcare Provider Details

I. General information

NPI: 1295149920
Provider Name (Legal Business Name): MUNJERINA AHMD MUNMUN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41900 FENWICK ST STE 1
LEONARDTOWN MD
20650-3815
US

IV. Provider business mailing address

41900 FENWICK ST STE 1
LEONARDTOWN MD
20650-3815
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-8860
  • Fax:
Mailing address:
  • Phone: 301-475-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0083883
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: