Provider Demographics
NPI:1619680196
Name:SUD, DISHA (LAC)
Entity Type:Individual
Prefix:
First Name:DISHA
Middle Name:
Last Name:SUD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 POLARA PL
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2045
Mailing Address - Country:US
Mailing Address - Phone:240-421-2691
Mailing Address - Fax:
Practice Address - Street 1:912 THAYER AVE STE 105
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-5734
Practice Address - Country:US
Practice Address - Phone:240-641-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist