Basic Information
| Provider Information | |||||||||
| NPI: | 1881072338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHAJAN | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | HAN NGOC LE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAHAJAN | ||||||||
| OtherFirstName: | AUDREY | ||||||||
| OtherMiddleName: | LE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444741 | ||||||||
| FaxNumber: | 4014444445 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST STE E | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2678479559 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2015 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD471772 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MT216168 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.