Provider Demographics
NPI:1700027844
Name:KEITA, SHOMARKA OMAR (MD, DPHIL)
Entity Type:Individual
Prefix:DR
First Name:SHOMARKA
Middle Name:OMAR
Last Name:KEITA
Suffix:
Gender:M
Credentials:MD, DPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MARTIN LUTHER KING AV. SE
Mailing Address - Street 2:ST. ELIZABETHS HOSPITAL, DEPT. MENTAL HEALTH, HR
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032
Mailing Address - Country:US
Mailing Address - Phone:202-645-1076
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING AVE SE
Practice Address - Street 2:ST. ELIZABETHS HOSPITAL, DMH
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032
Practice Address - Country:US
Practice Address - Phone:202-645-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD18079208D00000X
MDD0025173208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC017206200Medicaid