Provider Demographics
NPI:1053874115
Name:MAHAPATRA, DEEP HANS
Entity type:Individual
Prefix:
First Name:DEEP
Middle Name:HANS
Last Name:MAHAPATRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BRIGHTWATER DR
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5156
Mailing Address - Country:US
Mailing Address - Phone:910-892-1000
Mailing Address - Fax:
Practice Address - Street 1:2 COLGATE DR STE 103
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2623
Practice Address - Country:US
Practice Address - Phone:410-420-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH96650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine