Healthcare Provider Details

I. General information

NPI: 1629654165
Provider Name (Legal Business Name): ERIC KOBENA SAFO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 BRANCH AVE STE 404
TEMPLE HILLS MD
20748-1251
US

IV. Provider business mailing address

20217 GENTLE WAY
GAITHERSBURG MD
20886-1204
US

V. Phone/Fax

Practice location:
  • Phone: 240-719-2587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP500004284
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP500004284
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR204606
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: