Provider Demographics
NPI:1033246814
Name:GANZER, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:GANZER
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:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0003
Mailing Address - Country:US
Mailing Address - Phone:304-234-1985
Mailing Address - Fax:304-234-6539
Practice Address - Street 1:58 16TH ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3660
Practice Address - Country:US
Practice Address - Phone:304-234-1985
Practice Address - Fax:304-234-6539
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13638207ND0101X, 207NS0135X
PAMD043359L207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A72258Medicare UPIN
PA636012Medicare ID - Type Unspecified
WV0536836Medicare ID - Type Unspecified