Provider Demographics
NPI:1568997617
Name:AVERSANO, ALEXANDER THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:THOMAS
Last Name:AVERSANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 N CHARLES ST STE 203
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5805
Mailing Address - Country:US
Mailing Address - Phone:443-849-3760
Mailing Address - Fax:443-849-8138
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6881
Practice Address - Country:US
Practice Address - Phone:443-849-8046
Practice Address - Fax:443-849-8057
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0093511207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD390200000XMedicaid
390200000XOtherPROVIDER