Healthcare Provider Details

I. General information

NPI: 1619973963
Provider Name (Legal Business Name): ELIZABETH S GANTT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9420 KEY WEST SUITE 202
ROCKVILLE MD
20850
US

IV. Provider business mailing address

PO BOX 37229
BALTIMORE MD
21297
US

V. Phone/Fax

Practice location:
  • Phone: 301-251-9555
  • Fax: 301-309-0765
Mailing address:
  • Phone: 240-485-5200
  • Fax: 301-625-6906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD41612
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: