Provider Demographics
NPI:1093941635
Name:DECESARE, GARY EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:DECESARE
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 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:10E-PBFS DEPARTMENT
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-3371
Practice Address - Street 1:311 N CLYDE MORRIS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2768
Practice Address - Country:US
Practice Address - Phone:386-238-2244
Practice Address - Fax:386-239-2381
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME123142208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid