Provider Demographics
NPI:1457698706
Name:JOSE P NEPOMUCENO MD PA
Entity Type:Organization
Organization Name:JOSE P NEPOMUCENO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEPOMUCENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-802-1206
Mailing Address - Street 1:7845 OAKWOOD RD
Mailing Address - Street 2:103
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4256
Mailing Address - Country:US
Mailing Address - Phone:410-768-2048
Mailing Address - Fax:410-768-9171
Practice Address - Street 1:7845 OAKWOOD RD
Practice Address - Street 2:103
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4256
Practice Address - Country:US
Practice Address - Phone:410-768-2048
Practice Address - Fax:410-768-9171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD16445261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD012126Medicaid
MDB69654Medicare UPIN
MD6392Medicare PIN