Provider Demographics
NPI:1316090855
Name:NETTEY, EBENEZER (MD)
Entity type:Individual
Prefix:MR
First Name:EBENEZER
Middle Name:
Last Name:NETTEY
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 1:10401 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-856-0334
Mailing Address - Fax:301-856-0709
Practice Address - Street 1:10401 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-932-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0036594207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36594100Medicaid
135101401Medicare ID - Type Unspecified
F22269Medicare UPIN