Provider Demographics
NPI:1144454141
Name:DORA MAMODESENE,MD,PC
Entity type:Organization
Organization Name:DORA MAMODESENE,MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DORA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAMODESENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-489-1277
Mailing Address - Street 1:2057 MAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-5564
Mailing Address - Country:US
Mailing Address - Phone:202-498-1277
Mailing Address - Fax:
Practice Address - Street 1:7733 ALASKA AVE NW
Practice Address - Street 2:NW
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1421
Practice Address - Country:US
Practice Address - Phone:202-882-5300
Practice Address - Fax:301-989-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029649MD261QP2300X
VA0101035678261QP2300X
DC14222MD261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000148491OtherMEDICARE
MD000148491OtherMEDICARE