Provider Demographics
NPI:1720010333
Name:JOHN KIJAK JR MD PA
Entity Type:Organization
Organization Name:JOHN KIJAK JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:PHELPS
Authorized Official - Last Name:HANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-253-4004
Mailing Address - Street 1:9815 MAIN ST
Mailing Address - Street 2:SUITE 41
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2002
Mailing Address - Country:US
Mailing Address - Phone:301-253-4004
Mailing Address - Fax:301-253-3391
Practice Address - Street 1:9815 MAIN ST
Practice Address - Street 2:SUITE 41
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-2002
Practice Address - Country:US
Practice Address - Phone:301-253-4004
Practice Address - Fax:301-253-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD09379Medicare UPIN
MDH51302Medicare UPIN