Provider Demographics
NPI:1477743870
Name:KONTAMWAR, MRIDUL
Entity Type:Individual
Prefix:
First Name:MRIDUL
Middle Name:
Last Name:KONTAMWAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ESSEX CENTER DR
Mailing Address - Street 2:INTERNAL MEDICINE
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2902
Mailing Address - Country:US
Mailing Address - Phone:978-977-4210
Mailing Address - Fax:978-977-4226
Practice Address - Street 1:2 ESSEX CENTER DR
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2902
Practice Address - Country:US
Practice Address - Phone:978-977-4210
Practice Address - Fax:978-977-4226
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085241207R00000X
MA235849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2159686Medicaid
MA000778902Medicare PIN