Provider Demographics
NPI:1154327872
Name:ALLEN, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:ALLEN
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:PO BOX 935921
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3310 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5250
Practice Address - Country:US
Practice Address - Phone:352-343-1216
Practice Address - Fax:352-343-1582
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80476208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258936200Medicaid
FL35578XMedicare ID - Type UnspecifiedINDIV. MEDICARE NUMBER
F71136Medicare UPIN
FL00364Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER