Basic Information
| Provider Information | |||||||||
| NPI: | 1548579642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFREITAS | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | ATT: CONTRACTING & CREDENTIALING | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144558 | ||||||||
| Practice Location | |||||||||
| Address1: | 14090 HG TRUEMAN RD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | SOLOMONS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206883151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103943712 | ||||||||
| FaxNumber: | 4103943714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT196731 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D0076619 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.