Healthcare Provider Details

I. General information

NPI: 1013960608
Provider Name (Legal Business Name): ANNA MARIE GONZAGA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

PO BOX 64260
BALTIMORE MD
21264-4260
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD57544
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD57544
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: