Provider Demographics
NPI:1063457471
Name:VANWIE, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:VANWIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73276
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21273-3276
Mailing Address - Country:US
Mailing Address - Phone:301-631-8103
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-4383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0062021207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD381221900Medicaid
MD001954200Medicaid
MD451601000Medicaid
MD001954200Medicaid
MD613LR946Medicare PIN
MDR946Medicare PIN
MDI20693Medicare UPIN
MDH254Medicare ID - Type UnspecifiedMEDICARE GRP #
MD381221900Medicaid
MDK034Medicare PIN