1407051709 NPI number — LETITIA KATHLENE THOMPSON DZIRASA M.D.

Table of content: LETITIA KATHLENE THOMPSON DZIRASA M.D. (NPI 1407051709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407051709 NPI number — LETITIA KATHLENE THOMPSON DZIRASA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON DZIRASA
Provider First Name:
LETITIA
Provider Middle Name:
KATHLENE
Provider Name Prefix Text:
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:
THOMPSON
Provider Other First Name:
LETITIA
Provider Other Middle Name:
KATHLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407051709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3501 SINCLAIR LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21213-2029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-732-8800
Provider Business Mailing Address Fax Number:
410-534-2392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1245 EASTERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESSEX
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21221-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-558-4700
Provider Business Practice Location Address Fax Number:
410-780-0364
Provider Enumeration Date:
06/18/2007

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: 208000000X , with the licence number:  22176 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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