Basic Information
Provider Information | |||||||||
NPI: | 1538161336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DECANDIDO | ||||||||
FirstName: | PAULA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2002 MEDICAL PKWY | ||||||||
Address2: | SUITE 235 | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214013046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102662770 | ||||||||
FaxNumber: | 4108416251 | ||||||||
Practice Location | |||||||||
Address1: | 2002 MEDICAL PKWY | ||||||||
Address2: | SUITE 235 | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214013046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102662770 | ||||||||
FaxNumber: | 4108416251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2005 | ||||||||
LastUpdateDate: | 11/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0038821 | MD | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300060330 | 01 | MD | TRAVELERS RR MEDICARE | OTHER | 8317071 | 01 | MD | AETNA PPO | OTHER | HN79 | 01 | MD | AAD AA COUNTY | OTHER | 10690021 | 01 | MD | BCBS | OTHER | 2622593 | 01 | MD | AETNA HMO/POS | OTHER | 731C | 01 | MD | AAD SHIPLEYS | OTHER | A04 | 01 | MD | AAD PG COUNTY | OTHER | 588231100 | 05 | MD |   | MEDICAID |