1730200155 NPI number — LAPLATA UROLOGY CENTER,LLC

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 1730200155 NPI number — LAPLATA UROLOGY CENTER,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAPLATA UROLOGY CENTER,LLC
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:
Provider Other Organization Name Type Code:
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:
1730200155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CENTENNIAL ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
LA PLATA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20646-5975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-392-0525
Provider Business Mailing Address Fax Number:
301-392-0458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CENTENNIAL ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
LA PLATA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20646-5975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-392-0525
Provider Business Practice Location Address Fax Number:
301-392-0458
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAKITELASHVILI
Authorized Official First Name:
VLADIMIR
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DOCTOR UROLOGY
Authorized Official Telephone Number:
301-392-0525

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  D0051225 , 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: K858 . This is a "CARE FIRST BC BS DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 281CLA . This is a "CARE FIRST BC BS MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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