Healthcare Provider Details

I. General information

NPI: 1619907789
Provider Name (Legal Business Name): KENNETH WILLIAM HAUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MUSGROVE RD SUITE 203
SILVER SPRING MD
20904-5200
US

IV. Provider business mailing address

2415 MUSGROVE RD SUITE 203
SILVER SPRING MD
20904-5200
US

V. Phone/Fax

Practice location:
  • Phone: 301-989-2300
  • Fax: 301-236-5357
Mailing address:
  • Phone: 301-989-2300
  • Fax: 301-236-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0022815
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: