Provider Demographics
NPI:1790940997
Name:CHESTER Z. HAVERBACK, M.D., CHARTERED
Entity Type:Organization
Organization Name:CHESTER Z. HAVERBACK, M.D., CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:Z
Authorized Official - Last Name:HAVERBACK, M.D.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-657-4747
Mailing Address - Street 1:8218 WISCONSIN AVENUE
Mailing Address - Street 2:#320
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814
Mailing Address - Country:US
Mailing Address - Phone:301-657-4747
Mailing Address - Fax:301-657-9065
Practice Address - Street 1:8218 WISCONSIN AVENUE
Practice Address - Street 2:#320
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-657-4747
Practice Address - Fax:301-657-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD05089208200000X
DCMD25318208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01214Medicare PIN