Provider Demographics
NPI:1972699809
Name:GARCIA-BOUSQUET, ELISDEL S (MD)
Entity type:Individual
Prefix:
First Name:ELISDEL
Middle Name:S
Last Name:GARCIA-BOUSQUET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 W. ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4596
Mailing Address - Country:US
Mailing Address - Phone:410-578-8600
Mailing Address - Fax:
Practice Address - Street 1:1708 W. ROGERS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4596
Practice Address - Country:US
Practice Address - Phone:410-578-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD51716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics