Provider Demographics
NPI:1205977915
Name:FANG, MARY H
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:FANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10931 MARTINGALE CT
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1500
Mailing Address - Country:US
Mailing Address - Phone:301-983-3795
Mailing Address - Fax:
Practice Address - Street 1:10931 MARTINGALE CT
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-1500
Practice Address - Country:US
Practice Address - Phone:301-983-3795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD23448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine