Healthcare Provider Details

I. General information

NPI: 1497730592
Provider Name (Legal Business Name): MAYURIKA GHOSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64442
BALTIMORE MD
21264-4442
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2463
  • Fax: 410-328-4430
Mailing address:
  • Phone: 410-328-2463
  • Fax: 410-328-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD61121
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: