=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396143210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSE SADIKMAN, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2014
-----------------------------------------------------
Last Update Date | 12/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 CONGRESSIONAL LN SUITE 402
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-793-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 CONGRESSIONAL LN SUITE 402
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-793-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | JESSE C. SADIKMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 240-793-5574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------