Healthcare Provider Details

I. General information

NPI: 1467385377
Provider Name (Legal Business Name): JESMANE ANTENOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAMUEL A ANTENOR ANTENOR

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 MOFFET RD
SILVER SPRING MD
20903-1936
US

IV. Provider business mailing address

1613 MOFFET RD
SILVER SPRING MD
20903-1936
US

V. Phone/Fax

Practice location:
  • Phone: 240-643-7477
  • Fax:
Mailing address:
  • Phone: 240-643-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberW21830419
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: