Provider Demographics
NPI:1922496462
Name:CAPITAL CENTER FOR FUNCTIONAL MEDICINE LLC
Entity Type:Organization
Organization Name:CAPITAL CENTER FOR FUNCTIONAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-892-2658
Mailing Address - Street 1:416 GREEN PASTURE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4233
Mailing Address - Country:US
Mailing Address - Phone:301-892-2658
Mailing Address - Fax:
Practice Address - Street 1:4701 SANGAMORE RD STE N270
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2528
Practice Address - Country:US
Practice Address - Phone:240-507-5110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD66066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014051100Medicaid