Basic Information
Provider Information | |||||||||
NPI: | 1295875763 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CALVERT DERMATOLOGY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1540 | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206781540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105354561 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 130 HOSPITAL RD | ||||||||
Address2: | STE. 200 | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105354561 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 09/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAWIT | ||||||||
AuthorizedOfficialFirstName: | FARIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | RESIDENT MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2022534401 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | D61859 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 412713700 | 05 | MD |   | MEDICAID |