Provider Demographics
NPI:1730252594
Name:SCIPIO - ETTIENNE, SUZETTE (MD)
Entity type:Individual
Prefix:
First Name:SUZETTE
Middle Name:
Last Name:SCIPIO - ETTIENNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZETTE
Other - Middle Name:SCIPIO
Other - Last Name:ETTIENNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2905 MITCHELLVILLE RD
Mailing Address - Street 2:STE 115
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1385
Mailing Address - Country:US
Mailing Address - Phone:301-390-7960
Mailing Address - Fax:301-218-2800
Practice Address - Street 1:2905 MITCHELLVILLE RD
Practice Address - Street 2:STE 115
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1385
Practice Address - Country:US
Practice Address - Phone:301-390-7960
Practice Address - Fax:301-218-2800
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046373208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD363101000Medicaid