Provider Demographics
NPI:1104248541
Name:MAFOT & ASSOCIATES MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:MAFOT & ASSOCIATES MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAGOBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-432-1924
Mailing Address - Street 1:11183 COLUMBIA PIKE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 MADISON PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6427
Practice Address - Country:US
Practice Address - Phone:410-487-6902
Practice Address - Fax:410-487-6982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-18
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0073466208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty