Provider Demographics
NPI:1205938305
Name:CHAMPALOUX, GERARD (MD)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:CHAMPALOUX
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 1:14300 GALLANT FOX LANE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4031
Mailing Address - Country:US
Mailing Address - Phone:301-262-6797
Mailing Address - Fax:301-262-2564
Practice Address - Street 1:14300 GALLANT FOX LANE
Practice Address - Street 2:SUITE 110
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4031
Practice Address - Country:US
Practice Address - Phone:301-262-6797
Practice Address - Fax:301-262-2564
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0020905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD784741600Medicaid
MD784741600Medicaid
MD409377Medicare ID - Type Unspecified