Basic Information
| Provider Information | |||||||||
| NPI: | 1104912328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UDESHI | ||||||||
| FirstName: | RUPAL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 ROBENA WAY | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135232156 | ||||||||
| FaxNumber: | 5135232503 | ||||||||
| Practice Location | |||||||||
| Address1: | 20010 CENTURY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208741115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406862300 | ||||||||
| FaxNumber: | 2406862330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | D0065767 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200826750 | 05 | IN | MEDICAID | 000000484329 | 01 | OH AND IN ANTHEM BCBS | OTHER | 2663498 | 05 | OH | MEDICAID |