Provider Demographics
NPI:1104912328
Name:UDESHI, RUPAL (MD)
Entity type:Individual
Prefix:
First Name:RUPAL
Middle Name:
Last Name:UDESHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 ROBENA WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:513-523-2156
Mailing Address - Fax:513-523-2503
Practice Address - Street 1:20010 CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1115
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:240-686-2330
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065767208000000X
IN01062172A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200826750Medicaid
000000484329OtherOH AND IN ANTHEM BCBS
OH2663498Medicaid