| Mukta Medical Inc | |
|
5415 Old Court Rd Suite 101 Randallstown MD 21133-5170 | |
| (410) 922-2650 | |
| (410) 922-1612 |
| Full Name | Mukta Medical Inc |
|---|---|
| Speciality | Internal Medicine |
| Location | 5415 Old Court Rd, Randallstown, Maryland |
| Authorized Official Name and Position | Mohammed Kiddugavu (OWNER) |
| Authorized Official Contact | 4109222650 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mukta Medical Inc Po Box 4784 Baltimore MD 21211-0784 Ph: (410) 922-2650 | Mukta Medical Inc 5415 Old Court Rd Suite 101 Randallstown MD 21133-5170 Ph: (410) 922-2650 |
| NPI Number | 1194197152 |
|---|---|
| Provider Enumeration Date | 10/29/2015 |
| Last Update Date | 09/14/2016 |
| Medicare PECOS PAC ID | 0941510382 |
|---|---|
| Medicare Enrollment ID | O20151113002279 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194197152 | NPI | - | NPPES |
| 901901400 | Medicaid | MD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207RI0200X | Internal Medicine - Infectious Disease | D0070832 (Maryland) | Primary |
| Provider Name | Mohammed G Kiddugavu |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1952446601 PECOS PAC ID: 3678762382 Enrollment ID: I20110112000152 |
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