Provider Demographics
NPI:1174341978
Name:DJEUTIO QUOIMON, ANDERSON ROY
Entity type:Individual
Prefix:
First Name:ANDERSON ROY
Middle Name:
Last Name:DJEUTIO QUOIMON
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 1:702 15TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4508
Mailing Address - Country:US
Mailing Address - Phone:202-388-8500
Mailing Address - Fax:
Practice Address - Street 1:13117 CRUTCHFIELD AVE # MD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3212
Practice Address - Country:US
Practice Address - Phone:240-644-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker