Provider Demographics
NPI:1053419614
Name:PEDRAZA, ROBERTO (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:PEDRAZA
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 1:25 CROSSROADS DRIVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:
Practice Address - Street 1:9420 KEY WEST AVE.
Practice Address - Street 2:#420
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-258-1919
Practice Address - Fax:301-258-9180
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056187208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD398641101Medicaid
012601U22Medicare ID - Type Unspecified
H94882Medicare UPIN