Healthcare Provider Details

I. General information

NPI: 1649235888
Provider Name (Legal Business Name): OPAL COURT PEDIATRICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 OPAL COURT SUITE A
HAGERSTOWN MD
21740-5976
US

IV. Provider business mailing address

1141 OPAL COURT SUITE A
HAGERSTOWN MD
21740-5976
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-6666
  • Fax: 301-791-4549
Mailing address:
  • Phone: 301-791-6666
  • Fax: 301-791-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ATCHUTHANAND BUDI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-791-6666