Provider Demographics
NPI:1689604654
Name:DECHOSA, VIVIAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:C
Last Name:DECHOSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:VIVIAN
Other - Middle Name:C
Other - Last Name:CASABAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 SOLAREX CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 SOLAREX CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8624
Practice Address - Country:US
Practice Address - Phone:301-682-5500
Practice Address - Fax:301-663-8557
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MD411053600Medicaid
MD451LMedicare PIN
I57798Medicare UPIN
MD411053600Medicaid
MDO251Medicare PIN
MD411053600Medicaid