Healthcare Provider Details

I. General information

NPI: 1831305481
Provider Name (Legal Business Name): LOUIS MARK COSENTINO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18409 MCKERNON WAY
POOLESVILLE MD
20837-2505
US

IV. Provider business mailing address

18409 MCKERNON WAY
POOLESVILLE MD
20837-2505
US

V. Phone/Fax

Practice location:
  • Phone: 301-349-5691
  • Fax:
Mailing address:
  • Phone: 301-349-5691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103000772
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: