Provider Demographics
NPI:1548579642
Name:DEFREITAS, KENDALL NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:NICHOLAS
Last Name:DEFREITAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:ATT: CONTRACTING & CREDENTIALING
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4017
Mailing Address - Country:US
Mailing Address - Phone:410-414-4791
Mailing Address - Fax:410-414-4558
Practice Address - Street 1:14090 HG TRUEMAN RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688-3151
Practice Address - Country:US
Practice Address - Phone:410-394-3712
Practice Address - Fax:410-394-3714
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2014-01-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMT196731207Q00000X
MDD0076619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RES0000Medicare UPIN