Provider Demographics
NPI:1609076108
Name:UDUGAMPOLA, BIANCA (MD)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:UDUGAMPOLA
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 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8913
Mailing Address - Fax:240-439-8910
Practice Address - Street 1:1562 OPOSSUMTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-662-8119
Practice Address - Fax:240-439-8910
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67750207R00000X
MO2007021138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO325491390Medicare PIN