Provider Demographics
NPI:1518904648
Name:MA, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MA
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 1:210 CHESAPEAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6395
Mailing Address - Country:US
Mailing Address - Phone:410-620-0545
Mailing Address - Fax:
Practice Address - Street 1:4853 PULASKI HWY
Practice Address - Street 2:STE 300
Practice Address - City:PERRYVILLE
Practice Address - State:MD
Practice Address - Zip Code:21903-1606
Practice Address - Country:US
Practice Address - Phone:410-642-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK729U499OtherMEDICARE
MD142661300Medicaid
MDF43807Medicare UPIN