1154313062 NPI number — DR. GARY C. PRADA M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154313062 NPI number — DR. GARY C. PRADA M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PRADA

Provider First Name:

GARY

Provider Middle Name:

C.

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

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:

1154313062

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/24/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1111 BENFIELD BLVD

Provider Second Line Business Mailing Address:

SUITE 200

Provider Business Mailing Address City Name:

MILLERSVILLE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21108-3002

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-729-5100

Provider Business Mailing Address Fax Number:

410-729-5156

Provider First Line Business Practice Location Address:

11055 LITTLE PATUXENT PKWY

Provider Second Line Business Practice Location Address:

SUITE 104

Provider Business Practice Location Address City Name:

COLUMBIA

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21044-2896

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-740-2900

Provider Business Practice Location Address Fax Number:

410-740-2955

Provider Enumeration Date:

08/17/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  D0022587 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1342957 . This is a "CIGNA PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 243371 . This is a "MAMSI SPECIALIST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 443211800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 3509-0005 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 4238655 . This is a "AETNA FEE FOR SERVICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 024210 . This is a "JHHC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 0477640 . This is a "AETNA CAPITATED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 843371 . This is a "MAMSI PRIMARY CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 110140826 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 524039-01 . This is a "CAREFIRST MD RENDERING" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: P12723 . This is a "CAREFIRST MPOS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".