Provider Demographics
NPI:1558305870
Name:KWINTKIEWICZ, LARYSA DAGMARA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARYSA
Middle Name:DAGMARA
Last Name:KWINTKIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARYSA
Other - Middle Name:DAGMARA
Other - Last Name:BLUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-7943
Mailing Address - Fax:410-328-3494
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-7943
Practice Address - Fax:410-328-3494
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD64611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD888744-01OtherBC/BS
MD410713600Medicaid
MD410713600Medicaid
MD888744-01OtherBC/BS
MDP00650034Medicare PIN