Healthcare Provider Details

I. General information

NPI: 1003927146
Provider Name (Legal Business Name): DONALD W. WICZER, M.D., GEORGE M. KORENGOLD, M.D., VANESSA M. MAYOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 SEVEN LOCKS ROAD # 238
POTOMAC MD
20854
US

IV. Provider business mailing address

11325 SEVEN LOCKS ROAD # 238
POTOMAC MD
20854
US

V. Phone/Fax

Practice location:
  • Phone: 301-299-8930
  • Fax: 301-299-8933
Mailing address:
  • Phone: 301-299-8930
  • Fax: 301-299-8933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0017886
License Number StateMD

VIII. Authorized Official

Name: DR. GEORGE M. KORENGOLD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-299-8930