Healthcare Provider Details

I. General information

NPI: 1053677518
Provider Name (Legal Business Name): JONATHAN DAMON LAWLESS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 NEW HAMPSHIRE AVE STE 411
SILVER SPRING MD
20904-2620
US

IV. Provider business mailing address

11120 NEW HAMPSHIRE AVE STE 411
SILVER SPRING MD
20904-2620
US

V. Phone/Fax

Practice location:
  • Phone: 301-754-0505
  • Fax:
Mailing address:
  • Phone: 301-754-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberH0083410
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: