Healthcare Provider Details

I. General information

NPI: 1972091668
Provider Name (Legal Business Name): MARY DIVYA KASU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6716
  • Fax: 410-706-5103
Mailing address:
  • Phone: 410-328-6716
  • Fax: 410-706-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0099777
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: