Healthcare Provider Details

I. General information

NPI: 1982313524
Provider Name (Legal Business Name): BESPOKE AESTHETIC PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 BLACKWELL RD STE 260
ROCKVILLE MD
20850-6487
US

IV. Provider business mailing address

9601 BLACKWELL RD STE 260
ROCKVILLE MD
20850-6487
US

V. Phone/Fax

Practice location:
  • Phone: 301-500-0215
  • Fax: 301-238-7807
Mailing address:
  • Phone: 301-500-0215
  • Fax: 301-238-7807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NADYA CLARKE
Title or Position: OWNER
Credential: MD
Phone: 301-257-1619