Provider Demographics
NPI:1760566996
Name:DESAMITO, MARLENE GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:GABRIEL
Last Name:DESAMITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 TOLEDO TER
Mailing Address - Street 2:SUITE C105
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-4135
Mailing Address - Country:US
Mailing Address - Phone:301-559-3323
Mailing Address - Fax:301-599-3325
Practice Address - Street 1:3311 TOLEDO TER
Practice Address - Street 2:SUITE C105
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-4135
Practice Address - Country:US
Practice Address - Phone:301-559-3323
Practice Address - Fax:301-599-3325
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7221153OtherAETNA PROV. NO.
MD1203744OtherUHC/AMERICHOICE PROV. NO
MD1356020 00Medicaid
MD94909OtherAMERIGROUP PROV. NO.