1013989029 NPI number — DR. PANKAJ VAIDYA MD

Table of content: DR. PANKAJ VAIDYA MD (NPI 1013989029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013989029 NPI number — DR. PANKAJ VAIDYA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAIDYA
Provider First Name:
PANKAJ
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013989029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 LEONARDTOWN RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALDORF
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20601-3647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-645-5951
Provider Business Mailing Address Fax Number:
301-843-2384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 LEONARDTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-645-4320
Provider Business Practice Location Address Fax Number:
301-843-2384
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  D0070404 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: E3821 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152360001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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