Provider Demographics
NPI:1518908169
Name:GAUDET, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:GAUDET
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:PO BOX 1980
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-1980
Mailing Address - Country:US
Mailing Address - Phone:276-218-0032
Mailing Address - Fax:276-276-9260
Practice Address - Street 1:1773 ROSE RIDGE
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-218-0032
Practice Address - Fax:276-276-9260
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036758207P00000X
VA0101367586207PE0004X
MDD354612083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD549841400Medicaid
VA5600378000Medicaid
VA1518908169Medicaid
VA1518908169Medicaid
002879S72Medicare ID - Type Unspecified
MD549841400Medicaid
VA5600378000Medicaid
VAVAA100815Medicare PIN