Provider Demographics
NPI:1619945557
Name:GWYNN, MARJORIE BERNADETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:BERNADETTE
Last Name:GWYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7671 QUARTERFIELD ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-766-0111
Mailing Address - Fax:410-582-9155
Practice Address - Street 1:7671 QUARTERFIELD ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-766-0111
Practice Address - Fax:410-582-9155
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699816000Medicaid
00A610A72Medicare ID - Type Unspecified
MD699816000Medicaid
H45703Medicare UPIN