Healthcare Provider Details

I. General information

NPI: 1790953065
Provider Name (Legal Business Name): POOLESVILLE FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19710 FISHER AVE SUITE J
POOLESVILLE MD
20837-0108
US

IV. Provider business mailing address

19710 FISHER AVE SUITE J, PO BOX 108
POOLESVILLE MD
20837-2098
US

V. Phone/Fax

Practice location:
  • Phone: 301-972-7600
  • Fax: 301-972-8006
Mailing address:
  • Phone: 301-972-7600
  • Fax: 301-972-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH61505
License Number StateMD

VIII. Authorized Official

Name: DR. AMAR VENKAT DUGGIRALA
Title or Position: FAMILY PHYSICIAN
Credential: D.O.
Phone: 301-972-7600