Healthcare Provider Details

I. General information

NPI: 1346204559
Provider Name (Legal Business Name): GARY M. DRAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8105 RITCHIE HWY
PASADENA MD
21122-3905
US

IV. Provider business mailing address

PO BOX 759047
BALTIMORE MD
21275-9047
US

V. Phone/Fax

Practice location:
  • Phone: 443-573-0564
  • Fax: 443-573-0565
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH0076645
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: