=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295769834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUKESH N MATHUR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3995 OLD TOWN RD SUITE 202
-----------------------------------------------------
City | HUNTINGTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20639-3041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-1451
-----------------------------------------------------
Fax | 410-535-9620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CALVERT INTERNAL MEDICINE GROUP, P.A. 985 PRINCE FREDERICK BLVD., STE 201
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-3042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-2005
-----------------------------------------------------
Fax | 443-432-3683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D-0025435
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------