Provider Demographics
NPI:1134477664
Name:DZATI, ALBERT LEGRAND SOMO
Entity Type:Individual
Prefix:
First Name:ALBERT LEGRAND
Middle Name:SOMO
Last Name:DZATI
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 1:14304 DRIFTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3044
Mailing Address - Country:US
Mailing Address - Phone:202-904-4216
Mailing Address - Fax:
Practice Address - Street 1:14304 DRIFTWOOD RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-3044
Practice Address - Country:US
Practice Address - Phone:240-260-3951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218461363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health