Provider Demographics
NPI:1801172622
Name:DIGREGORIO, IDALEE WAGMAN (LAC)
Entity type:Individual
Prefix:
First Name:IDALEE
Middle Name:WAGMAN
Last Name:DIGREGORIO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3534
Mailing Address - Country:US
Mailing Address - Phone:410-454-0178
Mailing Address - Fax:443-552-0319
Practice Address - Street 1:715 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4711
Practice Address - Country:US
Practice Address - Phone:410-454-0178
Practice Address - Fax:443-552-0319
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01942171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist