Healthcare Provider Details

I. General information

NPI: 1316979701
Provider Name (Legal Business Name): PRIME DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 FORBES BLVD
LANHAM MD
20706-4314
US

IV. Provider business mailing address

4451 BROOKFIELD CORPORATE DR STE 205
CHANTILLY VA
20151-1693
US

V. Phone/Fax

Practice location:
  • Phone: 301-459-5200
  • Fax: 301-459-5400
Mailing address:
  • Phone: 703-378-8100
  • Fax: 703-378-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21-D1057808
License Number StateMD

VIII. Authorized Official

Name: MS. SUJWALA PUTTAGUNTA BOPPUDI
Title or Position: PRESIDENT
Credential: MS, MBA
Phone: 301-459-5200