Provider Demographics
NPI:1336256502
Name:MALHOTRA, MUDITA (MD)
Entity type:Individual
Prefix:
First Name:MUDITA
Middle Name:
Last Name:MALHOTRA
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 1:9901 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3357
Mailing Address - Country:US
Mailing Address - Phone:301-251-9503
Mailing Address - Fax:
Practice Address - Street 1:1775 TYSONS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TYSONS
Practice Address - State:VA
Practice Address - Zip Code:22102-4285
Practice Address - Country:US
Practice Address - Phone:202-660-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI478696010Medicaid
MM068536OtherCHAMPUS-CHAMPUS
080H262390OtherBLUE CROSS-BLUE CROSS
MM068536OtherCOMMERCIAL-COMMERCIAL NUMBER
080H262390OtherBLUE CROSS-BLUE CROSS
H41388Medicare UPIN