=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588074645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY MEDICAL PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2014
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7226 LEE DEFOREST DR SUITE 206
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21046-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-878-7087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7226 LEE DEFOREST DR SUITE 206
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21046-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. IULIANA KETA SELARU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 443-878-7087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D0065430
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------