Provider Demographics
NPI:1972753028
Name:MUTHU, VASUNDHARA (MD)
Entity type:Individual
Prefix:MS
First Name:VASUNDHARA
Middle Name:
Last Name:MUTHU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3995 OLD TOWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-3039
Mailing Address - Country:US
Mailing Address - Phone:410-535-3612
Mailing Address - Fax:410-535-3613
Practice Address - Street 1:3995 OLD TOWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-9407
Practice Address - Country:US
Practice Address - Phone:410-535-3612
Practice Address - Fax:410-535-3613
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0075408207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD114505300Medicaid
MD306496ZAW7Medicare PIN