Healthcare Provider Details

I. General information

NPI: 1699202176
Provider Name (Legal Business Name): MUDIT KUMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 06/09/2022
Certification Date: 06/03/2022
Deactivation Date: 12/18/2017
Reactivation Date: 05/12/2018

III. Provider practice location address

VCU VIRGINIA TREATMENT CENTER FOR CHILDREN 1308 SHERWOOD AVENUE
RICHMOND VA
23220
US

IV. Provider business mailing address

VCU VIRGINIA TREATMENT CENTER FOR CHILDREN 1308 SHERWOOD AVENUE
RICHMOND VA
23220
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-3129
  • Fax:
Mailing address:
  • Phone: 804-828-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberLP04907
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101273958
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: