Provider Demographics
NPI:1477625788
Name:WEDAM, SUPARNA BONTHALA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPARNA
Middle Name:BONTHALA
Last Name:WEDAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUPARNA
Other - Middle Name:PANDU
Other - Last Name:BONTHALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5845 TUDOR LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2850
Mailing Address - Country:US
Mailing Address - Phone:301-468-2689
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:BLDG 8, RM 5101
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-496-0901
Practice Address - Fax:301-496-0047
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057865207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology