Provider Demographics
NPI:1134124563
Name:PALMER, GARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:PALMER
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 1:6720 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2161
Mailing Address - Country:US
Mailing Address - Phone:937-433-4922
Mailing Address - Fax:937-433-6520
Practice Address - Street 1:6720 LOOP RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2161
Practice Address - Country:US
Practice Address - Phone:937-433-4922
Practice Address - Fax:937-433-6520
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043172207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA80504Medicare UPIN
OHPA0522787Medicare ID - Type Unspecified