Provider Demographics
NPI:1770521130
Name:IM, DWIGHT D (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:D
Last Name:IM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:301 SAINT PAUL PL
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 ST. PAUL PLACE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9002
Practice Address - Fax:410-783-5880
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0043934207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS186 / 0013OtherBLUECHOICE
MDKT93ST / 528170-06OtherBC / BS OF MD
MD447571200Medicaid
165L / 056BMedicare ID - Type Unspecified
F62686Medicare UPIN