Provider Demographics
NPI:1588820971
Name:OUWINGA, IMMIRNE MONET (MD)
Entity Type:Individual
Prefix:DR
First Name:IMMIRNE
Middle Name:MONET
Last Name:OUWINGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:
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 1:10845 TOWN CENTER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-2712
Practice Address - Country:US
Practice Address - Phone:410-535-5660
Practice Address - Fax:410-535-5722
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128568207Q00000X
IL125055374207Q00000X
MDD78131207QA0401X
MDD0078131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDXO4799219OtherDEA BUPRENORPHINE WAIVER