1285700369 NPI number — MR. MUDIT SHARMA MD

Table of content: MR. MUDIT SHARMA MD (NPI 1285700369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285700369 NPI number — MR. MUDIT SHARMA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARMA
Provider First Name:
MUDIT
Provider Middle Name:
Provider Name Prefix Text:
MR.
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:
1285700369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9625 SURVEYOR COURT
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-921-4877
Provider Business Mailing Address Fax Number:
571-208-0585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9625 SURVEYOR COURT
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-921-4877
Provider Business Practice Location Address Fax Number:
571-208-0585
Provider Enumeration Date:
11/28/2006

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: 207T00000X , with the licence number:  MD035546 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 0101241433 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0101241433 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: MD035546 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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