Healthcare Provider Details

I. General information

NPI: 1255443727
Provider Name (Legal Business Name): GARY J SPROUSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 DIDONATO DR
CHESTER MD
21619-2628
US

IV. Provider business mailing address

2108 DIDONATO DR
CHESTER MD
21619-2628
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-6205
  • Fax: 410-643-6945
Mailing address:
  • Phone: 410-643-6205
  • Fax: 410-643-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD32036
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: