Provider Demographics
NPI:1922196922
Name:PRIBADI, JEAN WAHYUDIATI (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:WAHYUDIATI
Last Name:PRIBADI
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 1:10632 LITTLE PATUXENT PARKWAY
Mailing Address - Street 2:SUITE 111
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6212
Mailing Address - Country:US
Mailing Address - Phone:410-997-9751
Mailing Address - Fax:410-997-9763
Practice Address - Street 1:10632 LITTLE PATUXENT PARKWAY
Practice Address - Street 2:SUITE 111
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6212
Practice Address - Country:US
Practice Address - Phone:410-997-9751
Practice Address - Fax:410-997-9763
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD30510208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B70802Medicare UPIN
MD7518Medicare ID - Type Unspecified