1205920246 NPI number — DR. CLAUDINE H DESAMOURS M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205920246 NPI number — DR. CLAUDINE H DESAMOURS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESAMOURS
Provider First Name:
CLAUDINE
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GBAGUIDI
Provider Other First Name:
CLAUDINE
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205920246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10302 BRISTOW CENTER DR
Provider Second Line Business Mailing Address:
ST 173
Provider Business Mailing Address City Name:
BRISTOW
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20136-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-454-9944
Provider Business Mailing Address Fax Number:
540-680-2143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10302 BRISTOW CENTER DR
Provider Second Line Business Practice Location Address:
ST 173
Provider Business Practice Location Address City Name:
BRISTOW
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20136-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-454-9944
Provider Business Practice Location Address Fax Number:
540-680-2143
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  0101236758 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205920246 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 292852 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 249158 . This is a "KAISER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 139180 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: K142-0001 . This is a "CARE FIRST 2005" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00322422 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 484645 . This is a "NCPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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