Provider Demographics
NPI:1295308245
Name:WOLDE, ALTA
Entity type:Individual
Prefix:
First Name:ALTA
Middle Name:
Last Name:WOLDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 STRATHMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3482
Mailing Address - Country:US
Mailing Address - Phone:301-806-4280
Mailing Address - Fax:
Practice Address - Street 1:12850 MIDDLEBROOK RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-5255
Practice Address - Country:US
Practice Address - Phone:301-972-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194447207K00000X
MD521907944207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty