Provider Demographics
NPI:1053487108
Name:ERDY, GARY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:PAUL
Last Name:ERDY
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 1:214 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-2173
Mailing Address - Country:US
Mailing Address - Phone:740-845-4100
Mailing Address - Fax:
Practice Address - Street 1:214 ELM ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-2173
Practice Address - Country:US
Practice Address - Phone:740-845-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040231207Q00000X
OH35049219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072641Medicaid
IN100094310Medicaid
IN100094310Medicaid
OHH104170Medicare PIN
IN080042795Medicare PIN
IN257900 I I I IMedicare PIN
IN100094310Medicaid
OHH104170Medicare PIN