Provider Demographics
NPI:1578035135
Name:GWENDOLYN V YOUNGBLOOD, MD, PC
Entity Type:Organization
Organization Name:GWENDOLYN V YOUNGBLOOD, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:VIRGINIA
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-441-4555
Mailing Address - Street 1:7525 GREENWAY CENTER DR STE 311
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3525
Mailing Address - Country:US
Mailing Address - Phone:301-441-4555
Mailing Address - Fax:301-441-3420
Practice Address - Street 1:7525 GREENWAY CENTER DR STE 311
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3525
Practice Address - Country:US
Practice Address - Phone:301-441-4555
Practice Address - Fax:301-441-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD195661201Medicaid