Active NPI
Krystal Medical Associates LLC
- Primary Care Clinic/Center
- Glenn Dale, MD
National Provider Identifier
1164604187
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Primary Care Clinic/Center
- License
- D0053461
- Legal business name
- KRYSTAL MEDICAL ASSOCIATES LLC
- Doing business as
- Krystal Medical Associates
- Practice address
- 12150 Annapolis Rd Ste 100
Glenn Dale, MD 20769-9183 - Phone
- (301) 464-7601
- Fax
- (866) 885-9817
- NPI assigned
- Nov 30, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Nwaehihie Harrison Onyeaghala
- Title
- Owner
- Phone
- (301) 464-7601
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Multi-Specialty Clinic/Center | 261QM1300X | D0053461 | MD | |
| Primary Care Clinic/Center | 261QP2300X | D0053461 | MD | Primary |
Addresses
Primary practice location
12150 Annapolis Rd Ste 100
Glenn Dale, MD 20769-9183
Mailing address
PO Box 7321
Largo, MD 20792-7321
Phone (301) 464-7601
Other practice location 1
650 Pennsylvania Ave SE
Washington, DC 20003-4318
Phone (301) 464-7601
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 034934800 | Medicaid | DC | |
| 010012902 | Medicaid | VA | |
| 402647100 | Medicaid | MD | |
| 552123800 | Medicaid | MD |
Other names 1
- Krystal Medical Associates
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in DC
Enrollment records 1
National Provider Directory
National Provider Directory- Tax ID family
- Krystal Medical Associates LLC
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- In Home Supportive Care Agency
- Annandale, VA
- NPI 1578248787
Locations
1328 Southern Ave SE
Ste 307
Washington, DC 20032
Phone (202) 563-5485
12150 Annapolis Rd
Ste 100
Glenn Dale, MD 20769
Phone (301) 464-7601
Practitioners & affiliated clinicians
Practitioners 6
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Case Manager/Care Coordinator
- Hyattsville, MD
- NPI 1639042054
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1196380800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1788480000000",
"number": "1164604187",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 7321",
"city": "LARGO",
"state": "MD",
"postal_code": "207927321",
"telephone_number": "301-464-7601",
"fax_number": "866-885-9817"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12150 ANNAPOLIS RD STE 100",
"city": "GLENN DALE",
"state": "MD",
"postal_code": "207699183",
"telephone_number": "301-464-7601",
"fax_number": "866-885-9817"
}
],
"practiceLocations": [
{
"address_1": "650 Pennsylvania Ave SE",
"address_purpose": "LOCATION",
"city": "Washington",
"state": "DC",
"postal_code": "200034318",
"country_code": "US",
"telephone_number": "301-464-7601",
"fax_number": "866-885-9817",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"organization_name": "KRYSTAL MEDICAL ASSOCIATES LLC",
"organizational_subpart": "NO",
"enumeration_date": "2007-11-30",
"last_updated": "2026-09-04",
"certification_date": "2026-09-04",
"status": "A",
"authorized_official_last_name": "ONYEAGHALA",
"authorized_official_first_name": "NWAEHIHIE",
"authorized_official_middle_name": "HARRISON",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "301-464-7601"
},
"taxonomies": [
{
"code": "261QM1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Multi-Specialty",
"state": "MD",
"license": "D0053461",
"primary": false
},
{
"code": "261QP2300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Primary Care",
"state": "MD",
"license": "D0053461",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "034934800",
"state": "DC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "010012902",
"state": "VA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "402647100",
"state": "MD"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "552123800",
"state": "MD"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Krystal Medical Associates",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Glenn Dale, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.