Provider Demographics
NPI:1538466032
Name:IGENE, EJEMEARE P (OD)
Entity Type:Individual
Prefix:DR
First Name:EJEMEARE
Middle Name:P
Last Name:IGENE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6205 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-2908
Practice Address - Country:US
Practice Address - Phone:410-744-0199
Practice Address - Fax:410-744-0093
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002016152W00000X
MDTA2237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0721506Medicaid