Organization
MUKTA MEDICAL INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MOHAMMED KIDDUGAVU M.D. (OWNER)
(410) 922-2650
Entity
Organization
Contact information
Practice address
5415 OLD COURT RD, SUITE 101, RANDALLSTOWN, MD 21133-5170
(410) 922-2650
(410) 922-1612
Mailing address
PO BOX 4784, BALTIMORE, MD 21211-0784
(410) 922-2650
(410) 922-1612
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
D0070832
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
901901400
—
MD
Enumeration date
10/29/2015
Last updated
09/14/2016
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