Healthcare Provider Details

I. General information

NPI: 1164035895
Provider Name (Legal Business Name): MALKA TZIPORAH WIDOFSKY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10723 COLUMBIA PIKE STE B
SILVER SPRING MD
20901-4445
US

IV. Provider business mailing address

11216 PRELUDE CT
SILVER SPRING MD
20901-5057
US

V. Phone/Fax

Practice location:
  • Phone: 301-754-3730
  • Fax:
Mailing address:
  • Phone: 908-875-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02759
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: