Provider Demographics
NPI:1639819212
Name:OTHEPA, EUGIDE KASONGO (MD)
Entity type:Individual
Prefix:DR
First Name:EUGIDE
Middle Name:KASONGO
Last Name:OTHEPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EUGIDE
Other - Middle Name:
Other - Last Name:KASONGO-OTHEPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7045 ANTEBELLUM WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7479
Mailing Address - Country:US
Mailing Address - Phone:571-458-9569
Mailing Address - Fax:
Practice Address - Street 1:10614 RACETRACK RD UNIT 5
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3383
Practice Address - Country:US
Practice Address - Phone:410-208-9761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0102990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program