Provider Demographics
NPI:1972512408
Name:DEBRA, KWASI A (MD)
Entity Type:Individual
Prefix:
First Name:KWASI
Middle Name:A
Last Name:DEBRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:STE 123
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-552-9495
Mailing Address - Fax:301-552-9743
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:STE 123
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-552-9495
Practice Address - Fax:301-552-9743
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040683207VG0400X
DCMD20163207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1026004806OtherCIGNA
MD925694OtherMAMSI
MDH9050001OtherBLUECROSS BLUESHIELD
MD52507102OtherCAREFIRST BC BS OF MD
MD4561470OtherAETNA
MD703633OtherUNITED HEALTHCARE
MD4561470OtherAETNA
MDP00166923Medicare ID - Type UnspecifiedRAILROAD
MDG01686Medicare ID - Type UnspecifiedTRAILBLAZER