Provider Demographics
NPI:1407823776
Name:GOPAL, JAY J (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:J
Last Name:GOPAL
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 1:10395 KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5851
Mailing Address - Country:US
Mailing Address - Phone:410-554-2919
Mailing Address - Fax:410-554-2570
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:33RD STREET BUILDING SUITE 233
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2829
Practice Address - Country:US
Practice Address - Phone:410-554-2696
Practice Address - Fax:410-554-2570
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD75859903OtherBLUE SHIELD
MDC57725Medicare UPIN
MD3717Medicare ID - Type Unspecified
MD761LM962Medicare PIN