Provider Demographics
NPI:1912994948
Name:GHOSHTAGORE, SRIRUPA (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIRUPA
Middle Name:
Last Name:GHOSHTAGORE
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 1:5005 RUSHLIGHT PATH
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-1298
Mailing Address - Country:US
Mailing Address - Phone:410-715-4961
Mailing Address - Fax:410-715-4961
Practice Address - Street 1:8450 DORSEY RUN RD
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:MD
Practice Address - Zip Code:20794-9486
Practice Address - Country:US
Practice Address - Phone:410-724-3089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00262222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD269341100Medicaid
MDB70373Medicare ID - Type Unspecified
MD269341100Medicaid