Healthcare Provider Details

I. General information

NPI: 1174660633
Provider Name (Legal Business Name): MRIDULA BANAJI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTH WASHINGTON STREET
FALLS CHURCH VA
22046
US

IV. Provider business mailing address

2101 EAST JEFFERSON STREET KAISER PERMANENTE, PPQA, 6 WEST,
ROCKVILLE MD
20852
US

V. Phone/Fax

Practice location:
  • Phone: 703-536-1500
  • Fax: 703-536-1395
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0059466
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD33954
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101233266
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: