Basic Information
| Provider Information | |||||||||
| NPI: | 1154313062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRADA | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | 4107295156 | ||||||||
| Practice Location | |||||||||
| Address1: | 11055 LITTLE PATUXENT PKWY | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210442896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107402900 | ||||||||
| FaxNumber: | 4107402955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0022587 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1342957 | 01 | MD | CIGNA PIN | OTHER | 243371 | 01 | MD | MAMSI SPECIALIST | OTHER | 443211800 | 05 | MD | MEDICAID | 3509-0005 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 4238655 | 01 | MD | AETNA FEE FOR SERVICE | OTHER | 024210 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 0477640 | 01 | MD | AETNA CAPITATED | OTHER | 843371 | 01 | MD | MAMSI PRIMARY CARE | OTHER | 110140826 | 01 | MD | RR MEDICARE | OTHER | 524039-01 | 01 | MD | CAREFIRST MD RENDERING | OTHER | P12723 | 01 | MD | CAREFIRST MPOS | OTHER |