Healthcare Provider Details

I. General information

NPI: 1487657227
Provider Name (Legal Business Name): GWENNETH O CANCINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BEL AIR AVENUE
ABERDEEN MD
21001-3221
US

IV. Provider business mailing address

115 W BEL AIR AVENUE
ABERDEEN MD
21001-3221
US

V. Phone/Fax

Practice location:
  • Phone: 410-272-3377
  • Fax: 410-273-1479
Mailing address:
  • Phone: 410-272-1692
  • Fax: 410-272-1694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0046268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: