Provider Demographics
NPI:1932302098
Name:LAMICHHANE, MADHAB (MD)
Entity Type:Individual
Prefix:
First Name:MADHAB
Middle Name:
Last Name:LAMICHHANE
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:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:14605 POTOMAC BRANCH DR STE 210
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3337
Practice Address - Country:US
Practice Address - Phone:703-780-9014
Practice Address - Fax:703-780-9077
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.123006207R00000X
WI67204207RA0001X
VA0101264702207RA0001X
MI4301098068207R00000X
IL125050611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301098068OtherPHYSICIAN LICENSE, BOARD OF MEDICINE
MI1932302098Medicaid
IL125-050611OtherPHYSICIAN TEMPORARY LICEN
IL036.123006OtherSTATE OF ILLINOIS DFPR PHYSICIAN LICENSURE
IL809840OtherMEDICARE GROUP PTAN
IL125-050611OtherPHYSICIAN TEMPORARY LICEN
MI1932302098Medicaid