Provider Demographics
NPI:1861453284
Name:WATHEN, GEORGE H (MD PA)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:WATHEN
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11345 PEMBROOKE SQ
Mailing Address - Street 2:STE 103
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4804
Mailing Address - Country:US
Mailing Address - Phone:301-645-8144
Mailing Address - Fax:301-870-8392
Practice Address - Street 1:11345 PEMBROOKE SQ
Practice Address - Street 2:SUITE 103
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4804
Practice Address - Country:US
Practice Address - Phone:301-645-8144
Practice Address - Fax:301-870-8392
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD326971000Medicaid
110128523OtherRR MEDICARE
MD223NMedicare PIN
110128523OtherRR MEDICARE
DCG02195G01Medicare PIN