Provider Demographics
NPI:1326083163
Name:FERNANDOPULLE, GREGORY CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHRISTOPHER
Last Name:FERNANDOPULLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 ELLICOTT CENTER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043
Mailing Address - Country:US
Mailing Address - Phone:410-461-3760
Mailing Address - Fax:410-461-0526
Practice Address - Street 1:3454 ELLICOTT CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043
Practice Address - Country:US
Practice Address - Phone:410-461-3760
Practice Address - Fax:410-461-0526
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD154012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E10426Medicare UPIN