Healthcare Provider Details

I. General information

NPI: 1376768234
Provider Name (Legal Business Name): MICHELLE T CHUDOW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 W ROGERS AVE DEPT OF
BALTIMORE MD
21209-4596
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 410-578-5202
  • Fax: 410-367-4196
Mailing address:
  • Phone: 484-628-0797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0068848
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: