Basic Information
Provider Information | |||||||||
NPI: | 1073993796 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RITA SHKULLAKU MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23 PIERSIDE DR | ||||||||
Address2: | APT 237 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212305463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108979841 | ||||||||
FaxNumber: | 4108979852 | ||||||||
Practice Location | |||||||||
Address1: | 23 PIERSIDE DR | ||||||||
Address2: | APT 237 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212305463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108979841 | ||||||||
FaxNumber: | 4108979852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2015 | ||||||||
LastUpdateDate: | 06/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHKULLAKU | ||||||||
AuthorizedOfficialFirstName: | RITA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
AuthorizedOfficialTelephone: | 4108979841 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0074339 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | D0074339 | 01 | MD | OWNER STATE LICENSE | OTHER |