Provider Demographics
NPI:1336259035
Name:GOTWALT, DARRYL
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:GOTWALT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 YORK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1526
Mailing Address - Country:US
Mailing Address - Phone:410-337-7705
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL DR STE 506A
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5887
Practice Address - Country:US
Practice Address - Phone:410-768-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD17450OtherLICENSE #