Provider Demographics
NPI:1285620922
Name:MITHANI, KAMRUDIN (MD)
Entity type:Individual
Prefix:DR
First Name:KAMRUDIN
Middle Name:
Last Name:MITHANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3721
Mailing Address - Country:US
Mailing Address - Phone:410-939-1050
Mailing Address - Fax:410-939-2010
Practice Address - Street 1:1106 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3721
Practice Address - Country:US
Practice Address - Phone:410-939-1050
Practice Address - Fax:410-939-2010
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD380121700Medicaid
GA5973OtherRRMC
MDB67285Medicare UPIN
MD380121700Medicaid