Healthcare Provider Details

I. General information

NPI: 1316696560
Provider Name (Legal Business Name): KEISHA PATRICIA TARGET MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 SILVER MOON DR
SILVER SPRING MD
20904-1249
US

IV. Provider business mailing address

ROCKLEY GOLF & COUNTRY CLUB, GOLF CLUB ROAD APT 225 GOLDEN GROVE CLUSTER
BRIDGETOWN CHRIST CHURCH
BB15121
BB

V. Phone/Fax

Practice location:
  • Phone: 954-305-6594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: