Provider Demographics
NPI:1265451470
Name:GANJOO, DIDA K (MD)
Entity Type:Individual
Prefix:
First Name:DIDA
Middle Name:K
Last Name:GANJOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIDA
Other - Middle Name:K
Other - Last Name:SOOD-GANJOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3060 MITCHELLVILLE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1389
Mailing Address - Country:US
Mailing Address - Phone:301-218-4220
Mailing Address - Fax:301-218-4330
Practice Address - Street 1:3060 MITCHELLVILLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1389
Practice Address - Country:US
Practice Address - Phone:301-218-4220
Practice Address - Fax:301-218-4330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00365322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD095591400Medicaid
MD095591400Medicaid
DC597630Medicare ID - Type Unspecified