Healthcare Provider Details

I. General information

NPI: 1619514049
Provider Name (Legal Business Name): DUNDALK MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 04/02/2022
Certification Date: 04/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WISE AVENUE
DUNDALK MD
21222-4911
US

IV. Provider business mailing address

207 WISE AVENUE
DUNDALK MD
21222-4911
US

V. Phone/Fax

Practice location:
  • Phone: 410-284-1004
  • Fax: 410-284-2109
Mailing address:
  • Phone: 410-284-1004
  • Fax: 410-284-2109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEEPAK SETH
Title or Position: OWNER
Credential: MD
Phone: 410-284-1004