Provider Demographics
NPI:1811945074
Name:ROTELLO, LEO C (MD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:C
Last Name:ROTELLO
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:PO BOX 791372
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1372
Mailing Address - Country:US
Mailing Address - Phone:301-608-8375
Mailing Address - Fax:301-608-3979
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-3100
Practice Address - Fax:301-896-2393
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052774207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
MDP00418895OtherMEDICARE RAILROAD
MD54824901OtherCAREFIRST BCBS
MD234910800Medicaid
MD54824902OtherCAREFIRST BCBS
DC74960001OtherCAREFIRST BCBS
DC19460007OtherCAREFIRST BCBS
DC034470600Medicaid
DC034470600Medicaid
MDP00418895OtherMEDICARE RAILROAD
MD54824901OtherCAREFIRST BCBS
DC19460007OtherCAREFIRST BCBS
DCG02860P11Medicare PIN