1467771774 NPI number — DEO GRACIAS FAUSTINO MD PA

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 1467771774 NPI number — DEO GRACIAS FAUSTINO MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEO GRACIAS FAUSTINO MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEOGRACIAS V. FAUSTINO (SOLO PRACTICE)
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467771774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 698
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPSTEAD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21074-0698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-374-4488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4111 LOWER BECKLEYSVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPSTEAD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21074-2248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-374-4488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FAUSTINO
Authorized Official First Name:
DEOGRACIAS
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERNIST
Authorized Official Telephone Number:
410-374-4488

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D0012901 , 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)

  • Identifier: D0012901 . This is a "DMHMH LICENSE NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 009431500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164504528 . This is a "SOLO PRACTICE NPI AS DEOGRACIAS V. FAUSTINO, M.D." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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