Healthcare Provider Details

I. General information

NPI: 1275599458
Provider Name (Legal Business Name): SURESHKUMAR MUTTATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 SARVIS AVE SUITE 200
RIVERDALE MD
20737-1394
US

IV. Provider business mailing address

5711 SARVIS AVE SUITE 200
RIVERDALE MD
20737-1394
US

V. Phone/Fax

Practice location:
  • Phone: 301-277-8100
  • Fax: 301-277-0668
Mailing address:
  • Phone: 301-277-8100
  • Fax: 301-277-0668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0058290
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: