Healthcare Provider Details

I. General information

NPI: 1578012118
Provider Name (Legal Business Name): BLAKE LEIBOWITZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14995 SHADY GROVE RD
ROCKVILLE MD
20850-8726
US

IV. Provider business mailing address

2730 UNIVERSITY BLVD W STE 310
WHEATON MD
20902-1990
US

V. Phone/Fax

Practice location:
  • Phone: 301-942-7600
  • Fax: 301-217-9241
Mailing address:
  • Phone: 301-942-7600
  • Fax: 301-942-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: