Provider Demographics
NPI:1376793810
Name:JEGATHESAN, MITHILA (MD)
Entity Type:Individual
Prefix:DR
First Name:MITHILA
Middle Name:
Last Name:JEGATHESAN
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 1:106 MILFORD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6959
Mailing Address - Country:US
Mailing Address - Phone:410-543-1616
Mailing Address - Fax:410-543-8497
Practice Address - Street 1:106 MILFORD ST STE 201
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6959
Practice Address - Country:US
Practice Address - Phone:410-543-1616
Practice Address - Fax:410-543-8497
Is Sole Proprietor?:No
Enumeration Date:2008-09-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076657208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
S118Medicare PIN
MD119591300Medicaid