Healthcare Provider Details

I. General information

NPI: 1548096084
Provider Name (Legal Business Name): THRIVE AND GROW PEDIATRIC ENDOCRINOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 EXECUTIVE BLVD STE 312
N BETHESDA MD
20852-3803
US

IV. Provider business mailing address

6000 EXECUTIVE BLVD STE 312
N BETHESDA MD
20852-3803
US

V. Phone/Fax

Practice location:
  • Phone: 240-553-5003
  • Fax: 240-553-5005
Mailing address:
  • Phone: 240-553-5003
  • Fax: 240-553-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AMITA DE SOUZA
Title or Position: MD, CEO
Credential: MD
Phone: 240-553-5003