Provider Demographics
NPI:1770116873
Name:HUMPHREY, MARK WILLIAM SR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:HUMPHREY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 ATLEE DR
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-5966
Mailing Address - Country:US
Mailing Address - Phone:240-330-0786
Mailing Address - Fax:
Practice Address - Street 1:3348 BLAINE ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1327
Practice Address - Country:US
Practice Address - Phone:202-399-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide