Provider Demographics
NPI:1609841188
Name:KILAVOS, MARY FREKKO (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:FREKKO
Last Name:KILAVOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ILONA
Other - Last Name:FREKKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:818 WEST DIAMOND AVENUE
Mailing Address - Street 2:STE 130
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878
Mailing Address - Country:US
Mailing Address - Phone:301-948-8780
Mailing Address - Fax:301-519-9093
Practice Address - Street 1:818 WEST DIAMOND AVENUE
Practice Address - Street 2:STE 130
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878
Practice Address - Country:US
Practice Address - Phone:301-948-8780
Practice Address - Fax:301-519-9093
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD492066OtherMEDICARE
MD492066OtherMEDICARE