Healthcare Provider Details

I. General information

NPI: 1154313062
Provider Name (Legal Business Name): GARY C. PRADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11055 LITTLE PATUXENT PKWY SUITE 104
COLUMBIA MD
21044-2896
US

IV. Provider business mailing address

1111 BENFIELD BLVD SUITE 200
MILLERSVILLE MD
21108-3002
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-2900
  • Fax: 410-740-2955
Mailing address:
  • Phone: 410-729-5100
  • Fax: 410-729-5156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0022587
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: