Healthcare Provider Details

I. General information

NPI: 1477855823
Provider Name (Legal Business Name): MARIO O BELLEDONNE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 TUCKERMAN LN
POTOMAC MD
20854-3744
US

IV. Provider business mailing address

8200 TUCKERMAN LN
POTOMAC MD
20854-3744
US

V. Phone/Fax

Practice location:
  • Phone: 301-605-7878
  • Fax: 301-605-7878
Mailing address:
  • Phone: 301-605-7878
  • Fax: 301-605-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD-23177
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD-23177
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD-23177
License Number StateMD

VIII. Authorized Official

Name: DR. MARIO O BELLEDONNE
Title or Position: PRESIDENT
Credential: MD
Phone: 301-605-7878