Provider Demographics
NPI:1568279800
Name:ELEZUA, MICAH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:ELEZUA
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 1:8662 BRAE BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3814
Mailing Address - Country:US
Mailing Address - Phone:202-430-8440
Mailing Address - Fax:
Practice Address - Street 1:702 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4508
Practice Address - Country:US
Practice Address - Phone:202-388-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker