Provider Demographics
NPI:1083615025
Name:SHINTANI, GARY A (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:SHINTANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6545
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-6545
Mailing Address - Country:US
Mailing Address - Phone:231-922-9270
Mailing Address - Fax:231-922-9271
Practice Address - Street 1:400 HOBART ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2331
Practice Address - Country:US
Practice Address - Phone:231-876-7200
Practice Address - Fax:231-876-6830
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013542207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4236844OtherMOLINA
MI110H310180OtherBC BILLING NUMBER
MI127835OtherPREF CHOICE BILLING NUMBE
MI27544OtherPRIORITY HEALTH
MI383552631057OtherCOMM CHOICE BILLING NUMBE
MI4236844Medicaid
MI0N17550002Medicare PIN
MI4236844Medicaid