Provider Demographics
NPI:1164934469
Name:SHASTRI, MITALI
Entity Type:Individual
Prefix:
First Name:MITALI
Middle Name:
Last Name:SHASTRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5513 DOWGATE CT APT D1
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20851-2037
Mailing Address - Country:US
Mailing Address - Phone:516-455-6586
Mailing Address - Fax:
Practice Address - Street 1:8 BALTIMORE RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4604
Practice Address - Country:US
Practice Address - Phone:516-455-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist