Provider Demographics
NPI:1679566186
Name:SOMERVILLE, IAN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:DOUGLAS
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3405
Mailing Address - Country:US
Mailing Address - Phone:410-939-5300
Mailing Address - Fax:410-939-6485
Practice Address - Street 1:400 LEWIS ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3405
Practice Address - Country:US
Practice Address - Phone:410-939-5300
Practice Address - Fax:410-939-6485
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14544174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB66893Medicare UPIN