Provider Demographics
NPI:1790213742
Name:EBURUOH, POLYCARP
Entity Type:Individual
Prefix:
First Name:POLYCARP
Middle Name:
Last Name:EBURUOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 ENOCH CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2111
Mailing Address - Country:US
Mailing Address - Phone:301-655-7114
Mailing Address - Fax:
Practice Address - Street 1:9500 ARENA DR STE 440F
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-3713
Practice Address - Country:US
Practice Address - Phone:301-655-7455
Practice Address - Fax:240-525-0892
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194007163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse