Provider Demographics
NPI:1366434789
Name:SOPREY, NISHA P (MD)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:P
Last Name:SOPREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NISHA
Other - Middle Name:K
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2300 GARRISON BLVD
Mailing Address - Street 2:SUITE 220 B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2335
Mailing Address - Country:US
Mailing Address - Phone:410-945-2484
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 220 B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-945-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0024476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB69773Medicare UPIN