Provider Demographics
NPI:1760542740
Name:NINALA, WILKINSON JESUDAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WILKINSON
Middle Name:JESUDAS
Last Name:NINALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 UNIVERSITY BLVD E STE 37
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-2915
Mailing Address - Country:US
Mailing Address - Phone:301-328-7155
Mailing Address - Fax:301-328-7182
Practice Address - Street 1:831 UNIVERSITY BLVD E STE 37
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-2915
Practice Address - Country:US
Practice Address - Phone:301-328-7155
Practice Address - Fax:301-328-7182
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045285207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD601181100Medicaid
MD601181101Medicaid
G14930Medicare UPIN