1356684302 NPI number — ROSARIO GONZAGA, MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356684302 NPI number — ROSARIO GONZAGA, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSARIO GONZAGA, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356684302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/21/2019
NPI Reactivation Date:
10/30/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
957 NATIONAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAVALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-729-9475
Provider Business Mailing Address Fax Number:
301-729-9474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
957 NATIONAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-729-9475
Provider Business Practice Location Address Fax Number:
301-729-9474
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GONZAGA
Authorized Official First Name:
ROMMEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-729-9475

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D39811 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: D22277 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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