Provider Demographics
NPI:1083800072
Name:GARY PYNCKEL D.O., P.A.
Entity Type:Organization
Organization Name:GARY PYNCKEL D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PYNCKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-278-3377
Mailing Address - Street 1:3840 COLONIAL BLVD. SUITE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966
Mailing Address - Country:US
Mailing Address - Phone:239-278-3377
Mailing Address - Fax:239-278-5266
Practice Address - Street 1:3840 COLONIAL BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966
Practice Address - Country:US
Practice Address - Phone:239-278-3377
Practice Address - Fax:239-278-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5324Medicare PIN
C45637Medicare UPIN