Provider Demographics
NPI:1194790394
Name:MCTIZIC, JOHN L
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:MCTIZIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 YARA WAY
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-8477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 W BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-1558
Practice Address - Country:US
Practice Address - Phone:410-362-3000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001017174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist