Provider Demographics
NPI:1619973963
Name:GANTT, ELIZABETH S (MD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:S
Last Name:GANTT
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:PO BOX 37229
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297
Mailing Address - Country:US
Mailing Address - Phone:240-485-5200
Mailing Address - Fax:301-625-6906
Practice Address - Street 1:9420 KEY WEST
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-251-9555
Practice Address - Fax:301-309-0765
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41612207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD751141800Medicaid
E42604Medicare UPIN
MD671088A66Medicare ID - Type Unspecified