Healthcare Provider Details

I. General information

NPI: 1609844018
Provider Name (Legal Business Name): WALDORF INTEGRATED HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29015 THREE NOTCH RD SUITE 1-A
MECHANICSVILLE MD
20659-3228
US

IV. Provider business mailing address

PO BOX 1565
WALDORF MD
20604-1565
US

V. Phone/Fax

Practice location:
  • Phone: 301-290-5285
  • Fax: 301-290-5287
Mailing address:
  • Phone: 301-645-9551
  • Fax: 301-645-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOAN BARKER
Title or Position: OFFICE MANAGER
Credential: CMM
Phone: 301-645-9551