Healthcare Provider Details

I. General information

NPI: 1982134805
Provider Name (Legal Business Name): TRINA CHAKRABORTTY RIDOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E 31ST ST
BALTIMORE MD
21218-3902
US

IV. Provider business mailing address

1 E 31ST ST
BALTIMORE MD
21218-3902
US

V. Phone/Fax

Practice location:
  • Phone: 410-516-9270
  • Fax: 410-516-4784
Mailing address:
  • Phone: 410-516-5270
  • Fax: 410-416-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD89795
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: