Provider Demographics
NPI:1750370342
Name:SHOWALTER, ILEANA (MD)
Entity type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:SHOWALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SAINT PAUL PL
Mailing Address - Street 2:APT. 1002
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2270
Mailing Address - Country:US
Mailing Address - Phone:410-837-8286
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:SUITE 612
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-837-6126
Practice Address - Fax:410-539-3418
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405908500Medicaid
MD405908500Medicaid