Provider Demographics
NPI:1518230515
Name:BENNING ROAD PRIMARY CARE PC
Entity Type:Organization
Organization Name:BENNING ROAD PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ISMAIL
Authorized Official - Middle Name:MUSTAPHA
Authorized Official - Last Name:KALOKOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-397-2200
Mailing Address - Street 1:PO BOX 3703
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20791-3703
Mailing Address - Country:US
Mailing Address - Phone:202-397-2200
Mailing Address - Fax:202-397-2688
Practice Address - Street 1:1647 BENNING RD NE
Practice Address - Street 2:SUITE 304
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4569
Practice Address - Country:US
Practice Address - Phone:202-397-2200
Practice Address - Fax:202-397-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD21581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC017134100Medicaid
DC490186Medicare PIN
DCG74179Medicare UPIN