Provider Demographics
NPI:1356684302
Name:ROSARIO GONZAGA, MD PA
Entity Type:Organization
Organization Name:ROSARIO GONZAGA, MD PA
Other - Org Name:GONZAGA PEDIATRICS AND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROMMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-729-9475
Mailing Address - Street 1:957 NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502
Mailing Address - Country:US
Mailing Address - Phone:301-729-9475
Mailing Address - Fax:301-729-9474
Practice Address - Street 1:957 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-729-9475
Practice Address - Fax:301-729-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2023-08-17
Deactivation Date:2019-10-21
Deactivation Code:
Reactivation Date:2019-10-30
Provider Licenses
StateLicense IDTaxonomies
MDD39811207Q00000X
MDD22277208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty