Provider Demographics
NPI:1063564458
Name:AYERS, C. EMMANUEL (MD)
Entity type:Individual
Prefix:
First Name:C. EMMANUEL
Middle Name:
Last Name:AYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 S DAKOTA AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-3253
Mailing Address - Country:US
Mailing Address - Phone:773-383-9777
Mailing Address - Fax:
Practice Address - Street 1:7450 ALBERT RD
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3035
Practice Address - Country:US
Practice Address - Phone:301-888-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109654207V00000X, 208D00000X
MDD0070960207V00000X
DCMD0349049207V00000X
MI4301120119207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0070960Medicaid
DC0349049Medicaid
IL036109654Medicaid
MI4301120119Medicaid
MDK22059Medicare UPIN