MEDICARE: MRIGENDRA MANI BASTOLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	5784	MD

General Provider Information

NPI Number	:	1639024839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRIGENDRA MANI BASTOLA MD

Provider Business Mailing Address
First Line	:	7601 QUINTANA CT
Second Line	:
City	:	BETHESDA
State	:	MD
Zip	:	20817-2042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7601 QUINTANA CT
Second Line	:
City	:	BETHESDA
State	:	MD
Zip	:	20817-2042
Country	:	US
Telephone Number	:	251-753-1454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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