Healthcare Provider Details

I. General information

NPI: 1568063758
Provider Name (Legal Business Name): INNOVATIVE PEDIATRICS & MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 FERRARA DR
SILVER SPRING MD
20906
US

IV. Provider business mailing address

3921 FERRARA DR
SILVER SPRING MD
20906
US

V. Phone/Fax

Practice location:
  • Phone: 301-337-8846
  • Fax: 301-946-0642
Mailing address:
  • Phone: 301-337-8846
  • Fax: 301-946-0642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GIFTY AFETA
Title or Position: CLINICAN
Credential: MD
Phone: 301-337-8846