Provider Demographics
NPI:1679637979
Name:GATTUSO, ROBERT LEROY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEROY
Last Name:GATTUSO
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 1:16940 YORK RD
Mailing Address - Street 2:SUITE 204B
Mailing Address - City:MONKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21111-1095
Mailing Address - Country:US
Mailing Address - Phone:410-357-4500
Mailing Address - Fax:410-357-4570
Practice Address - Street 1:16940 YORK RD
Practice Address - Street 2:SUITE 204B
Practice Address - City:MONKTON
Practice Address - State:MD
Practice Address - Zip Code:21111-1095
Practice Address - Country:US
Practice Address - Phone:410-357-4500
Practice Address - Fax:410-357-4570
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034622207Q00000X, 208600000X
FLME 70600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3502OtherBLUE CROSS BLUE SHIELD
MD561351500Medicaid
MD3502Medicare ID - Type Unspecified
MD3502OtherBLUE CROSS BLUE SHIELD