Healthcare Provider Details

I. General information

NPI: 1689201626
Provider Name (Legal Business Name): RADHIKA GHODASARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

14618 GREEN BIRCH DR
PINEVILLE NC
28134-9043
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5000
  • Fax:
Mailing address:
  • Phone: 704-526-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9478
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: