Healthcare Provider Details

I. General information

NPI: 1528370152
Provider Name (Legal Business Name): MALLIKA S PATEL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 WISCONSIN AVE NW
WASHINGTON DC
20016-2160
US

IV. Provider business mailing address

3015 NICOSH CIR UNIT #2403
FALLS CHURCH VA
22042-1235
US

V. Phone/Fax

Practice location:
  • Phone: 202-237-8500
  • Fax:
Mailing address:
  • Phone: 540-250-6674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2213
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001972
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP1000202
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: