Provider Demographics
NPI:1326082884
Name:MATHUR, KRISHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHAN
Middle Name:
Last Name:MATHUR
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:PO BOX 2729
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-2729
Mailing Address - Country:US
Mailing Address - Phone:301-645-4242
Mailing Address - Fax:301-705-7512
Practice Address - Street 1:3500 OLD WASHINGTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3224
Practice Address - Country:US
Practice Address - Phone:301-645-4242
Practice Address - Fax:301-705-7512
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28352207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD301331600Medicaid
35150501OtherCAREFIRST BC BS
3600310OtherUHC
4376960OtherAETNA
38917OtherMAMSI
35150501OtherCAREFIRST BC BS
MD5937Medicare PIN
4376960OtherAETNA
MD170449ZFL2Medicare PIN