Provider Demographics
NPI:1003967639
Name:EBERLY, GARY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:EBERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:LEE
Other - Last Name:EBERLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:19713 16TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8095
Mailing Address - Country:US
Mailing Address - Phone:253-846-9419
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41014207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine