Healthcare Provider Details

I. General information

NPI: 1417995143
Provider Name (Legal Business Name): RAJENDER KUMAR GATTU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 REISTERSTOWN RD
PIKESVILLE MD
21208-3808
US

IV. Provider business mailing address

1419 REISTERSTOWN RD
PIKESVILLE MD
21208-3808
US

V. Phone/Fax

Practice location:
  • Phone: 240-376-1616
  • Fax: 855-825-6158
Mailing address:
  • Phone: 240-376-1616
  • Fax: 855-825-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301073223
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberD66275
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD66275
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: