Healthcare Provider Details

I. General information

NPI: 1952915472
Provider Name (Legal Business Name): BERYL ACHIENG OTIENO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST STE 203
TOWSON MD
21204-5805
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-3760
  • Fax: 443-849-8138
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD98374
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberD98374
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: