Healthcare Provider Details

I. General information

NPI: 1265896252
Provider Name (Legal Business Name): RIYAD GARGOUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N CAROLINE ST # 3235A
BALTIMORE MD
21287-0006
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-9446
  • Fax: 410-614-0431
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD91581
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: