Provider Demographics
NPI:1114953452
Name:BHOGAVILLI, SUNITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNITHA
Middle Name:
Last Name:BHOGAVILLI
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-0157
Mailing Address - Country:US
Mailing Address - Phone:301-570-9700
Mailing Address - Fax:301-260-2838
Practice Address - Street 1:9801 GEORGIA AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5276
Practice Address - Country:US
Practice Address - Phone:301-592-0461
Practice Address - Fax:301-260-2838
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD634000800Medicaid
MD19DMSOtherBLUE CROSS BLUE SHIELD
DC52550001OtherBLUE CROSS
G02185S01Medicare PIN
DC52550001OtherBLUE CROSS