=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275507550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEEP KUKRETI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 07/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9900 WASHINGTON BLVD STE L
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-776-4996
-----------------------------------------------------
Fax | 301-483-8810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9900 WASHINGTON BLVD STE L
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-776-4996
-----------------------------------------------------
Fax | 301-483-8810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DOO52075
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------