Provider Demographics
NPI:1396833604
Name:DAVE, MITUL N (MD)
Entity Type:Individual
Prefix:DR
First Name:MITUL
Middle Name:N
Last Name:DAVE
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 1:9055 CHEVROLET DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043
Mailing Address - Country:US
Mailing Address - Phone:410-465-7850
Mailing Address - Fax:410-465-3713
Practice Address - Street 1:9055 CHEVROLET DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042
Practice Address - Country:US
Practice Address - Phone:410-465-7950
Practice Address - Fax:410-465-3716
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD057313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD374000500Medicaid
MD262SMedicare PIN
MD374000500Medicaid