Provider Demographics
NPI:1265470181
Name:GWATHNEY, JAMAL KAVON (MD, MPH, FAAFP)
Entity type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:KAVON
Last Name:GWATHNEY
Suffix:
Gender:M
Credentials:MD, MPH, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14706 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-5641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3720 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1548
Practice Address - Country:US
Practice Address - Phone:202-279-1800
Practice Address - Fax:202-279-4349
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD35077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036832600Medicaid
DCH78813Medicare UPIN
DC010890W40Medicare ID - Type Unspecified
DC036832600Medicaid