Provider Demographics
NPI:1114096765
Name:NACKMAN, GARY B (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:NACKMAN
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 1:1037 US HIGHWAY 46
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2451
Mailing Address - Country:US
Mailing Address - Phone:973-778-2222
Mailing Address - Fax:973-860-1148
Practice Address - Street 1:1037 US HIGHWAY 46
Practice Address - Street 2:SUITE 202
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2451
Practice Address - Country:US
Practice Address - Phone:973-778-2222
Practice Address - Fax:973-860-1148
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA648372086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7069707Medicaid
NJ760000191OtherRR MCR PTAN
NJ7069707Medicaid
NJ894196Medicare PIN