Healthcare Provider Details

I. General information

NPI: 1528217494
Provider Name (Legal Business Name): SHRUTI PRADEEP MUTALIK M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 E 17TH ST APARTMENT 23 E
NEW YORK NY
10003-3821
US

IV. Provider business mailing address

8901 WISCONSIN AVE
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 203-848-9123
  • Fax:
Mailing address:
  • Phone: 301-295-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number272213
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number272213
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number272213
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: