Provider Demographics
NPI:1174660633
Name:BANAJI, MRIDULA (MD)
Entity Type:Individual
Prefix:DR
First Name:MRIDULA
Middle Name:
Last Name:BANAJI
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 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:KAISER PERMANENTE, PPQA, 6 WEST,
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:201 NORTH WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046
Practice Address - Country:US
Practice Address - Phone:703-536-1500
Practice Address - Fax:703-536-1395
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059466208000000X
DCMD33954208000000X
VA0101233266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G88170Medicare UPIN
015034K92Medicare ID - Type Unspecified