Provider Demographics
NPI:1104842566
Name:GONZAGA, MELVIN R (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:R
Last Name:GONZAGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:957 NATIONAL HWY, STE 3
Mailing Address - Street 2:ATTN: MELVIN GONZAGA
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21501-0929
Mailing Address - Country:US
Mailing Address - Phone:240-362-7128
Mailing Address - Fax:240-362-7129
Practice Address - Street 1:957 NATIONAL HWY, STE 3
Practice Address - Street 2:ATTN: MELVIN GONZAGA
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21501-0929
Practice Address - Country:US
Practice Address - Phone:240-362-7128
Practice Address - Fax:240-362-7129
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22148207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD961521100Medicaid
D71969Medicare UPIN
MD712M255FMedicare ID - Type Unspecified