Provider Demographics
NPI:1952516619
Name:VEA, CARISSA JEAN ILDEFONSO (MD)
Entity Type:Individual
Prefix:
First Name:CARISSA JEAN
Middle Name:ILDEFONSO
Last Name:VEA
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 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:6000 EXECUTIVE BLVD STE 625
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3877
Practice Address - Country:US
Practice Address - Phone:240-314-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188480207Q00000X
MDD0069419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine