Healthcare Provider Details

I. General information

NPI: 1407823776
Provider Name (Legal Business Name): JAY J GOPAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E UNIVERSITY PKWY 33RD STREET BUILDING SUITE 233
BALTIMORE MD
21218-2829
US

IV. Provider business mailing address

10395 KINGSBRIDGE RD
ELLICOTT CITY MD
21042-5851
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-2696
  • Fax: 410-554-2570
Mailing address:
  • Phone: 410-554-2919
  • Fax: 410-554-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD31052
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: