Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036128568 | IL |
N | 207Q00000X | Family Doctor | 125055374 | IL |
Y | 207Q00000X | Family Doctor | D0078131 | MD |
N | 207QA0401X | Family Doctor - Addiction Medicine | D78131 | MD |
NPI | 1588820971 |
---|---|
Provider Name | Dr. Immirne Monet Ouwinga |
First Address | Prince Frederick, MD 20678-4017 |
Second Address | Dunkirk, MD 20754-2712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2008 |
Last Update Date | 18/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
XO4799219 | DEA BUPRENORPHINE WAIVER (01) | MD |