Provider Demographics
NPI:1184627457
Name:GONZAGA, ROSARIO (MD)
Entity type:Individual
Prefix:DR
First Name:ROSARIO
Middle Name:
Last Name:GONZAGA
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 1:957 NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7328
Mailing Address - Country:US
Mailing Address - Phone:301-729-9475
Mailing Address - Fax:301-729-9474
Practice Address - Street 1:957 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7328
Practice Address - Country:US
Practice Address - Phone:301-729-9475
Practice Address - Fax:301-729-9474
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22277208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
7124551OtherCIGNA
WV0112098000OtherMEDICAID
840445OtherMAMSI
7124551OtherCIGNA