1548292022 NPI number — MYTHILY VANCHA MD

Table of content: MYTHILY VANCHA MD (NPI 1548292022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548292022 NPI number — MYTHILY VANCHA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANCHA
Provider First Name:
MYTHILY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1548292022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9602 DIXON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20723-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-575-4755
Provider Business Mailing Address Fax Number:
301-238-7833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 RESEARCH BLVD STE 330
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-6255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-686-8554
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2006

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: 207R00000X , with the licence number:  D0064760 , 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: 1000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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