Basic Information
| Provider Information | |||||||||
| NPI: | 1588820971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OUWINGA | ||||||||
| FirstName: | IMMIRNE | ||||||||
| MiddleName: | MONET | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144558 | ||||||||
| Practice Location | |||||||||
| Address1: | 10845 TOWN CENTER BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DUNKIRK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207542712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105355660 | ||||||||
| FaxNumber: | 4105355722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036128568 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 125055374 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | D78131 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | D0078131 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | XO4799219 | 01 | MD | DEA BUPRENORPHINE WAIVER | OTHER |