Provider Demographics
NPI:1447529904
Name:DURU, VIVIAN NDIRIKA (PA)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:NDIRIKA
Last Name:DURU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:NDIRIKA
Other - Last Name:OKPALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7580 BUCKINGHAM BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-3210
Mailing Address - Country:US
Mailing Address - Phone:410-729-5100
Mailing Address - Fax:
Practice Address - Street 1:24 MAGOTHY BEACH RD STE A
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4414
Practice Address - Country:US
Practice Address - Phone:410-255-2700
Practice Address - Fax:410-437-1962
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00004666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD310866OtherKAISER PERMANENTE
MD9774810OtherAETNA PPO
MD8393492OtherAETNA HMO
MD236243Y5ZMedicare PIN