Provider Demographics
NPI:1477599843
Name:INDRISANO, JEFFREY PETER (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PETER
Last Name:INDRISANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 PULASKI PARK DR
Mailing Address - Street 2:103
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1400
Mailing Address - Country:US
Mailing Address - Phone:443-725-8762
Mailing Address - Fax:410-780-8790
Practice Address - Street 1:6410 ROCKLEDGE DR
Practice Address - Street 2:SUITE 401
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1809
Practice Address - Country:US
Practice Address - Phone:301-890-5001
Practice Address - Fax:301-890-5193
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0037975207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0037975OtherSTATE LICENSE NUMBER
BI1394650OtherDEA
E36916Medicare UPIN
594787E82Medicare ID - Type Unspecified