Provider Demographics
NPI:1477269447
Name:ICON MEDICINE
Entity type:Organization
Organization Name:ICON MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:NYAKANGO
Authorized Official - Last Name:ONSERIO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,APRN,FNP,CRNP
Authorized Official - Phone:240-966-4266
Mailing Address - Street 1:10770 COLUMBIA PIKE STE 300-1021
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4402
Mailing Address - Country:US
Mailing Address - Phone:240-966-4266
Mailing Address - Fax:301-235-1771
Practice Address - Street 1:7411 RIGGS RD STE 300B
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-4246
Practice Address - Country:US
Practice Address - Phone:240-966-4266
Practice Address - Fax:301-235-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR189170OtherCRNP LICENSE
FLAPRN11022989OtherAPRN LICENSE
VA0024189089OtherAPRN LICENSE
MDO-526793646572OtherDRIVERS LICENSE