Healthcare Provider Details

I. General information

NPI: 1417018946
Provider Name (Legal Business Name): IRVIN R MADURO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6014 OLD BRANCH AVE KAISER PERMANENTE CAMP SPRINGS MEDICAL CENTER
TEMPLE HILLS MD
20748-2518
US

IV. Provider business mailing address

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6 W KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 301-702-6100
  • Fax: 301-702-6366
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberMD22166
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberD0038713
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: