Provider Demographics
NPI:1164785382
Name:ULLERY, GARY MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:ULLERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-782-2380
Mailing Address - Fax:208-785-3504
Practice Address - Street 1:98 POPLAR ST FL 2
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-782-2380
Practice Address - Fax:208-785-3504
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0906208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics