Provider Demographics
NPI:1427876184
Name:BALTIMORE, DEREK DOMONIQUE
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:DOMONIQUE
Last Name:BALTIMORE
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 1:2239 FARRINGTON AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-1543
Mailing Address - Country:US
Mailing Address - Phone:202-699-5310
Mailing Address - Fax:
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7024
Practice Address - Country:US
Practice Address - Phone:202-547-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator