Provider Demographics
NPI:1184702599
Name:MUSSENDEN, PHILIP LAURENCE SR (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LAURENCE
Last Name:MUSSENDEN
Suffix:SR
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 1:1647 BENNING ROAD, N.E.
Mailing Address - Street 2:SUITE 300B
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4588
Mailing Address - Country:US
Mailing Address - Phone:202-396-4774
Mailing Address - Fax:202-396-8840
Practice Address - Street 1:1647 BENNING ROAD, N.E.
Practice Address - Street 2:SUITE 300B
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4588
Practice Address - Country:US
Practice Address - Phone:202-396-4774
Practice Address - Fax:202-396-8840
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD25777208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD005271000OtherMEDICAID
4278OtherBLUE CROSS BLUE SHIELD
DC022494800Medicaid
1871663200OtherFIRST HEALTH
175571Medicare ID - Type Unspecified
1871663200OtherFIRST HEALTH