Healthcare Provider Details

I. General information

NPI: 1043275449
Provider Name (Legal Business Name): MRUTHYUNJAYA GONCHIGAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 THOMAS JOHNSON DR SUITE 215
FREDERICK MD
21702-4397
US

IV. Provider business mailing address

196 THOMAS JOHNSON DR SUITE 215
FREDERICK MD
21702-4397
US

V. Phone/Fax

Practice location:
  • Phone: 301-668-9988
  • Fax: 301-668-9977
Mailing address:
  • Phone: 301-668-9988
  • Fax: 301-668-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberD0050726
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0050726
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: