Provider Demographics
NPI:1114145877
Name:UNTIVEROS, JESUS BENJAMIN (MEDICAL DEGREE)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:BENJAMIN
Last Name:UNTIVEROS
Suffix:
Gender:M
Credentials:MEDICAL DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 SHADY GROVE COURT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877
Mailing Address - Country:US
Mailing Address - Phone:301-330-4400
Mailing Address - Fax:301-330-7343
Practice Address - Street 1:8903 SHADY GROVE COURT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877
Practice Address - Country:US
Practice Address - Phone:301-330-4400
Practice Address - Fax:301-330-7343
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28671207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD049106Medicare ID - Type Unspecified
B70969Medicare UPIN