Healthcare Provider Details

I. General information

NPI: 1306042650
Provider Name (Legal Business Name): MAUSUMI LIDOGOSTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 03/17/2022
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

2429 MAYNARD RD
CHARLOTTE NC
28270-0753
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-5729
  • Fax: 704-316-9639
Mailing address:
  • Phone: 914-374-4243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number25MA11311600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number252677
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number2013-00634
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2013-00634
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: