Healthcare Provider Details

I. General information

NPI: 1376793810
Provider Name (Legal Business Name): MITHILA JEGATHESAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MILFORD ST STE 201
SALISBURY MD
21804-6959
US

IV. Provider business mailing address

106 MILFORD ST STE 201
SALISBURY MD
21804-6959
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-1616
  • Fax: 410-543-8497
Mailing address:
  • Phone: 410-543-1616
  • Fax: 410-543-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0076657
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: