Healthcare Provider Details

I. General information

NPI: 1992093355
Provider Name (Legal Business Name): DEEPTHI MOOLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 NORTH GLEBE RD #430
ARLINGTON VA
22201
US

IV. Provider business mailing address

1005 NORTH GLEBE RD #430
ARLINGTON VA
22201
US

V. Phone/Fax

Practice location:
  • Phone: 571-302-3920
  • Fax: 571-302-3920
Mailing address:
  • Phone: 571-302-3920
  • Fax: 571-302-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101258379
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: