Provider Demographics
NPI:1699202176
Name:KUMAR, MUDIT
Entity Type:Individual
Prefix:
First Name:MUDIT
Middle Name:
Last Name:KUMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VCU VIRGINIA TREATMENT CENTER FOR CHILDREN
Mailing Address - Street 2:1308 SHERWOOD AVENUE
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220
Mailing Address - Country:US
Mailing Address - Phone:804-828-3129
Mailing Address - Fax:
Practice Address - Street 1:VCU VIRGINIA TREATMENT CENTER FOR CHILDREN
Practice Address - Street 2:1308 SHERWOOD AVENUE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-828-3129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2022-06-09
Deactivation Date:2017-12-18
Deactivation Code:
Reactivation Date:2018-05-12
Provider Licenses
StateLicense IDTaxonomies
RILP049072084P0804X
390200000X
VA01012739582084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program