Healthcare Provider Details

I. General information

NPI: 1154019727
Provider Name (Legal Business Name): JULIAN GUDGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12707 THRUSH PL
UPPER MARLBORO MD
20772-5283
US

IV. Provider business mailing address

12707 THRUSH PL
UPPER MARLBORO MD
20772-5283
US

V. Phone/Fax

Practice location:
  • Phone: 202-499-9063
  • Fax:
Mailing address:
  • Phone: 202-499-9063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: