Healthcare Provider Details

I. General information

NPI: 1356684302
Provider Name (Legal Business Name): ROSARIO GONZAGA, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date: 10/21/2019
Reactivation Date: 10/30/2019

III. Provider practice location address

957 NATIONAL HWY
LAVALE MD
21502
US

IV. Provider business mailing address

957 NATIONAL HWY
LAVALE MD
21502
US

V. Phone/Fax

Practice location:
  • Phone: 301-729-9475
  • Fax: 301-729-9474
Mailing address:
  • Phone: 301-729-9475
  • Fax: 301-729-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD39811
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD22277
License Number StateMD

VIII. Authorized Official

Name: ROMMEL GONZAGA
Title or Position: CEO
Credential:
Phone: 301-729-9475