Provider Demographics
NPI:1184897738
Name:ANNETTE C. GONSALVES, MD
Entity type:Organization
Organization Name:ANNETTE C. GONSALVES, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONSALVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-843-0500
Mailing Address - Street 1:6 POST OFFICE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2746
Mailing Address - Country:US
Mailing Address - Phone:301-843-0500
Mailing Address - Fax:301-645-0041
Practice Address - Street 1:6 POST OFFICE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2746
Practice Address - Country:US
Practice Address - Phone:301-843-0500
Practice Address - Fax:301-645-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB69491Medicare UPIN