Provider Demographics
NPI:1467560805
Name:MAZUMDER, SUDIPTA (MD)
Entity Type:Individual
Prefix:
First Name:SUDIPTA
Middle Name:
Last Name:MAZUMDER
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 1:7108 PINEVILLE MATTHEWS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8380
Mailing Address - Country:US
Mailing Address - Phone:704-542-2191
Mailing Address - Fax:
Practice Address - Street 1:7108 PINEVILLE MATTHEWS RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8380
Practice Address - Country:US
Practice Address - Phone:704-542-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01321208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN21007Medicaid
NC5904629Medicaid
NC143TTOtherBCBS
NC1467560805Medicaid
NC5904629Medicaid
SCN21007Medicaid
NC2057615AMedicare PIN
NC2057615GMedicare PIN
NC2057615CMedicare PIN
NC1467560805Medicaid
NC2057615Medicare PIN