Provider Demographics
NPI:1275507550
Name:KUKRETI, DEEP (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEP
Middle Name:
Last Name:KUKRETI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 WASHINGTON BLVD
Mailing Address - Street 2:STE L
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723
Mailing Address - Country:US
Mailing Address - Phone:301-776-4996
Mailing Address - Fax:301-483-8810
Practice Address - Street 1:9900 WASHINGTON BLVD
Practice Address - Street 2:STE L
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723
Practice Address - Country:US
Practice Address - Phone:301-776-4996
Practice Address - Fax:301-483-8810
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO52075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD877610500Medicaid
MD877610500Medicaid
490635Medicare PIN