Healthcare Provider Details

I. General information

NPI: 1295712560
Provider Name (Legal Business Name): MAKAYA ADISA MULATO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 THOMAS JOHNSON DR STE 5
FREDERICK MD
21702-4879
US

IV. Provider business mailing address

190 THOMAS JOHNSON DR STE 5
FREDERICK MD
21702-4879
US

V. Phone/Fax

Practice location:
  • Phone: 12-007-4444
  • Fax: 833-907-0576
Mailing address:
  • Phone: 301-200-7444
  • Fax: 833-907-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0057961
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: