Provider Demographics
NPI:1861499634
Name:MAHESH MOONDRA, MD, PA
Entity Type:Organization
Organization Name:MAHESH MOONDRA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-546-5954
Mailing Address - Street 1:106 MILFORD ST
Mailing Address - Street 2:SUITE 504B
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6953
Mailing Address - Country:US
Mailing Address - Phone:410-546-5954
Mailing Address - Fax:410-219-3038
Practice Address - Street 1:106 MILFORD ST
Practice Address - Street 2:SUITE 504B
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6953
Practice Address - Country:US
Practice Address - Phone:410-546-5954
Practice Address - Fax:410-219-3038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000875602OtherMADE
843455OtherMAMS
21728011OtherUHC
510427OtherUSHC
251300OtherBSVA
545418200OtherMAMD
KA67MAOtherBSMD
110140803OtherMBRR
32014OtherDHP
30773OtherPP
000799857OtherAMERIHEALTH
4393240OtherAETN
MD545418200Medicaid
191308OtherAMERIGROUP
E475OtherBSDC
B67286Medicare UPIN
MD662L789CMedicare Oscar/Certification
191308OtherAMERIGROUP
KA67MAOtherBSMD
30773OtherPP