Healthcare Provider Details

I. General information

NPI: 1679936017
Provider Name (Legal Business Name): ERVAND KRISTOSTURYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18109 PRINCE PHILIP DR STE 200
OLNEY MD
20832-1524
US

IV. Provider business mailing address

18109 PRINCE PHILIP DR STE 200
OLNEY MD
20832-1524
US

V. Phone/Fax

Practice location:
  • Phone: 301-774-7115
  • Fax: 301-570-6662
Mailing address:
  • Phone: 301-774-7115
  • Fax: 301-570-6662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD210002753
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0091190
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: