Basic Information
| Provider Information | |||||||||
| NPI: | 1992788137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGAIZA | ||||||||
| FirstName: | JUSTINIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491282 | ||||||||
| FaxNumber: | 4107497821 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491282 | ||||||||
| FaxNumber: | 4107497821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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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 | 207RH0003X | D66198 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 478364 | 01 | US HEALTH CARE | OTHER | 017081 | 01 | BLUE SHIELD OF VA | OTHER | 830007450 | 01 | MC TRAVELERS | OTHER | 3600054 | 01 | UNITED HEALTH CARE | OTHER | 281223 | 01 | AMERIGROUP | OTHER | 3738 | 01 | BLUE SHIELD OF DC GRP | OTHER | 37380006 | 01 | CAPITAL CARE | OTHER | 0006 | 01 | BLUE SHIELD OF DC | OTHER | 259622 | 01 | ALLIANCE MDIPA | OTHER |