Provider Demographics
NPI:1235131210
Name:MENNIE, GARY ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROY
Last Name:MENNIE
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 1:2770 AERO DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-1518
Mailing Address - Country:US
Mailing Address - Phone:409-727-4642
Mailing Address - Fax:409-721-9774
Practice Address - Street 1:2770 AERO DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-1518
Practice Address - Country:US
Practice Address - Phone:409-727-4642
Practice Address - Fax:409-721-9774
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00033XMedicare PIN
TXG85976Medicare UPIN