Provider Demographics
NPI:1659584621
Name:ROBERT L. GATTUSO, M.D., PA
Entity Type:Organization
Organization Name:ROBERT L. GATTUSO, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:GATTUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:410-357-4500
Mailing Address - Street 1:106 MT CARMEL ROAD
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21120
Mailing Address - Country:US
Mailing Address - Phone:410-357-4500
Mailing Address - Fax:410-357-4570
Practice Address - Street 1:106 MT CARMEL ROAD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120
Practice Address - Country:US
Practice Address - Phone:410-357-4500
Practice Address - Fax:410-357-4570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT L. GATTUSO, M.D., PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-07
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034622207Q00000X, 208600000X
FLME70600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3502OtherBLUE CROSS BLUE SHIELD
MD561351500Medicaid
MDB-42303Medicare UPIN
MD3502Medicare ID - Type Unspecified
MD561351500Medicaid
MD237003YVZ - 945LMedicare PIN