Provider Demographics
NPI:1821259474
Name:BOMMADEVARA, DEEPTHI K (MD; MPH)
Entity type:Individual
Prefix:
First Name:DEEPTHI
Middle Name:K
Last Name:BOMMADEVARA
Suffix:
Gender:F
Credentials:MD; MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:DEPARTMENT OF HOSPITAL MEDICINE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2950
Practice Address - Country:US
Practice Address - Phone:443-444-4362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0009777207R00000X
MDD-00082788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1821259474Medicaid
DE226452ZAG8Medicare PIN