Provider Demographics
NPI:1003927146
Name:DONALD W. WICZER, M.D., GEORGE M. KORENGOLD, M.D., VANESSA M. MAYOL
Entity type:Organization
Organization Name:DONALD W. WICZER, M.D., GEORGE M. KORENGOLD, M.D., VANESSA M. MAYOL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KORENGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-299-8930
Mailing Address - Street 1:11325 SEVEN LOCKS ROAD
Mailing Address - Street 2:# 238
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854
Mailing Address - Country:US
Mailing Address - Phone:301-299-8930
Mailing Address - Fax:301-299-8933
Practice Address - Street 1:11325 SEVEN LOCKS ROAD
Practice Address - Street 2:# 238
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854
Practice Address - Country:US
Practice Address - Phone:301-299-8930
Practice Address - Fax:301-299-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017886208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS962OtherCAREFIRST OF MD
MD910821100Medicaid
DCC043OtherCAREFIRST/BLUE CHOICE