Provider Demographics
NPI:1366407280
Name:GOUTERMAN, RICHARD MARK (CO,CPED)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MARK
Last Name:GOUTERMAN
Suffix:
Gender:M
Credentials:CO,CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 RANDOLPH RD
Mailing Address - Street 2:SUITE #G-6
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2257
Mailing Address - Country:US
Mailing Address - Phone:301-570-5660
Mailing Address - Fax:
Practice Address - Street 1:4701 RANDOLPH RD
Practice Address - Street 2:SUITE #G-6
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2257
Practice Address - Country:US
Practice Address - Phone:301-570-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15216137222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0261230001Medicare ID - Type UnspecifiedMEDICARE