Provider Demographics
NPI:1073609160
Name:TART, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:TART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:316 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:#212
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-383-5777
Mailing Address - Fax:253-627-0855
Practice Address - Street 1:1628 SOUTH MILDRED
Practice Address - Street 2:#101
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465
Practice Address - Country:US
Practice Address - Phone:253-383-5777
Practice Address - Fax:253-627-0855
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00035918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1103589Medicaid
C22488Medicare UPIN
WA1103589Medicaid