1740634880 NPI number — DR. CARMEN ELENA CERVANTES PACURUCU MD

Table of content: DR. CARMEN ELENA CERVANTES PACURUCU MD (NPI 1740634880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740634880 NPI number — DR. CARMEN ELENA CERVANTES PACURUCU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERVANTES PACURUCU
Provider First Name:
CARMEN ELENA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CERVANTES PACURUCU
Provider Other First Name:
CARMEN ELENA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1740634880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/28/2016
NPI Reactivation Date:
12/16/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6201 GREENLEIGH AVE 2ND FLOOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLE RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 E. MONUMENT ST.
Provider Second Line Business Practice Location Address:
4TH FLOOR / SUITE 416
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-955-5268
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2016

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: 207V00000X , with the licence number:  D90474 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: D90474 , 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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