Provider Demographics
NPI:1710072749
Name:DIGESTIVE DISEASE CLINIC, LLC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:AFAM
Authorized Official - Last Name:OBIOHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-770-3334
Mailing Address - Street 1:11400 ROCKVILLE PIKE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3004
Mailing Address - Country:US
Mailing Address - Phone:301-770-3334
Mailing Address - Fax:301-770-3336
Practice Address - Street 1:11400 ROCKVILLE PIKE
Practice Address - Street 2:SUITE 108
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3004
Practice Address - Country:US
Practice Address - Phone:301-770-3334
Practice Address - Fax:301-770-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01682Medicare ID - Type Unspecified