Provider Demographics
NPI:1497730592
Name:GHOSH, MAYURIKA (MD)
Entity Type:Individual
Prefix:
First Name:MAYURIKA
Middle Name:
Last Name:GHOSH
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-2463
Mailing Address - Fax:410-328-4430
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-2463
Practice Address - Fax:410-328-4430
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61121207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0319OtherBC/BS REGIONAL
MD642473-01OtherBC/BS
MD407044500Medicaid
MDS062-0319OtherBC/BS REGIONAL
MDP00608510Medicare PIN
MD407044500Medicaid