Provider Demographics
NPI:1417067216
Name:GERARD P CHAMPALOUX MD
Entity Type:Organization
Organization Name:GERARD P CHAMPALOUX MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPALOUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-262-6296
Mailing Address - Street 1:14300 GALLANT FOX LANE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4031
Mailing Address - Country:US
Mailing Address - Phone:301-262-6797
Mailing Address - Fax:301-262-2564
Practice Address - Street 1:14300 GALLANT FOX LANE
Practice Address - Street 2:SUITE 110
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4031
Practice Address - Country:US
Practice Address - Phone:301-262-6797
Practice Address - Fax:301-262-2564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD784741600Medicaid
MD409377Medicare ID - Type Unspecified
MD784741600Medicaid