Provider Demographics
NPI:1962791442
Name:GREGORIO M. BELLOSO M.D. P.A.
Entity type:Organization
Organization Name:GREGORIO M. BELLOSO M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:BELLOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1410-341-6321
Mailing Address - Street 1:5302 CHINABERRY DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1265
Mailing Address - Country:US
Mailing Address - Phone:410-341-6321
Mailing Address - Fax:410-341-7082
Practice Address - Street 1:11974 EDGEHILL TERRACE RD
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-2105
Practice Address - Country:US
Practice Address - Phone:410-651-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD29505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46234Medicaid
MD46234Medicaid