Healthcare Provider Details

I. General information

NPI: 1275507550
Provider Name (Legal Business Name): DEEP KUKRETI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 WASHINGTON BLVD STE L
LAUREL MD
20723
US

IV. Provider business mailing address

9900 WASHINGTON BLVD STE L
LAUREL MD
20723
US

V. Phone/Fax

Practice location:
  • Phone: 301-776-4996
  • Fax: 301-483-8810
Mailing address:
  • Phone: 301-776-4996
  • Fax: 301-483-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOO52075
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: