1710976642 NPI number — WADIA R MULLA MD

Table of content: WADIA R MULLA MD (NPI 1710976642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710976642 NPI number — WADIA R MULLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLA
Provider First Name:
WADIA
Provider Middle Name:
R
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:
1710976642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 S STATE ST
Provider Second Line Business Mailing Address:
742 BUILDING
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19901-3530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-674-3970
Provider Business Mailing Address Fax Number:
302-672-2350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 S GOVERNORS AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19904-6920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-744-6220
Provider Business Practice Location Address Fax Number:
302-734-8454
Provider Enumeration Date:
10/13/2005

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: 207SG0201X , with the licence number:  MD043899L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD043899L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X , with the licence number: MD043899L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X , with the licence number: C1-0004719 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X , with the licence number: C1-0004719 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001243406005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001380ZA5H . This is a "GROUP MEMBER PTAN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com