Provider Demographics
NPI:1770620874
Name:BHOOSHAN, VIMLA (MD)
Entity type:Individual
Prefix:DR
First Name:VIMLA
Middle Name:
Last Name:BHOOSHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9739 AVENEL FARM DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-5413
Mailing Address - Country:US
Mailing Address - Phone:301-203-2247
Mailing Address - Fax:301-292-1172
Practice Address - Street 1:11711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5151
Practice Address - Country:US
Practice Address - Phone:301-203-2247
Practice Address - Fax:301-292-1172
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00252612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01996V01Medicare ID - Type Unspecified
E63894Medicare UPIN