Basic Information
| Provider Information | |||||||||
| NPI: | 1043219660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEDERMAN | ||||||||
| FirstName: | CARL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BERWYN HOUSE RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012200150 | ||||||||
| FaxNumber: | 3012201032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 VARNUM ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200172180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022697000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD9179 | DC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0021603 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101028941 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7219881-1600124 | 05 | VA | MEDICAID |