1194797142 NPI number — DR. CONSTANTINE A MISOUL MD

Table of content: DR. CONSTANTINE A MISOUL MD (NPI 1194797142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194797142 NPI number — DR. CONSTANTINE A MISOUL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISOUL
Provider First Name:
CONSTANTINE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1194797142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9601 PULASKI PARK DR
Provider Second Line Business Mailing Address:
SUITE 416
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220-1409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-933-5678
Provider Business Mailing Address Fax Number:
410-933-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2131 MARYLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218-5614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-234-1600
Provider Business Practice Location Address Fax Number:
410-727-4148
Provider Enumeration Date:
02/03/2006

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: 207X00000X , with the licence number:  D0033522 , 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: 351330 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 972631 . This is a "CAQH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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