Healthcare Provider Details

I. General information

NPI: 1316259732
Provider Name (Legal Business Name): UPENDRA MAHAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL RD
PRINCE FREDERICK MD
20678-4017
US

IV. Provider business mailing address

100 HOSPITAL RD
PRINCE FREDERICK MD
20678-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-4629
  • Fax: 410-414-4591
Mailing address:
  • Phone: 410-414-4791
  • Fax: 410-414-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0075310
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: