Healthcare Provider Details

I. General information

NPI: 1134002900
Provider Name (Legal Business Name): ENNOBLE HC DMV II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 WAYNE AVE STE 250
SILVER SPRING MD
20910-4433
US

IV. Provider business mailing address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

V. Phone/Fax

Practice location:
  • Phone: 240-744-0001
  • Fax:
Mailing address:
  • Phone: 551-295-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KUSHABHADRA DAS
Title or Position: CEO
Credential:
Phone: 862-812-9010