Healthcare Provider Details

I. General information

NPI: 1538394242
Provider Name (Legal Business Name): KRISHNAJ GOURAB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KERNAN DR
GWYNN OAK MD
21207-6665
US

IV. Provider business mailing address

2200 KERNAN DR
GWYNN OAK MD
21207-6665
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-1715
  • Fax:
Mailing address:
  • Phone: 410-448-6895
  • Fax: 410-448-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License NumberD76155
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD76155
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: