Healthcare Provider Details

I. General information

NPI: 1184627457
Provider Name (Legal Business Name): ROSARIO GONZAGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 NATIONAL HWY
LAVALE MD
21502-7328
US

IV. Provider business mailing address

957 NATIONAL HWY
LAVALE MD
21502-7328
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 TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD22277
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: