1437103595 NPI number — MANGAL KATIKINENI M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437103595 NPI number — MANGAL KATIKINENI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KATIKINENI
Provider First Name:
MANGAL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KATIKINENI
Provider Other First Name:
MANGAL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1437103595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6504 KENILWORTH AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20737-1386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-927-0088
Provider Business Mailing Address Fax Number:
301-927-7239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6502 KENILWORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20737-1340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-927-0088
Provider Business Practice Location Address Fax Number:
301-927-7239
Provider Enumeration Date:
05/20/2006

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: 207RN0300X , with the licence number:  D0026230 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 079201200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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