Provider Demographics
NPI:1245231828
Name:FINE, GARY D (DO, FACC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:FINE
Suffix:
Gender:M
Credentials:DO, FACC
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 11768
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1768
Mailing Address - Country:US
Mailing Address - Phone:479-484-1010
Mailing Address - Fax:479-785-9916
Practice Address - Street 1:4200 JENNY LIND ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-484-1010
Practice Address - Fax:479-785-9916
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127031003Medicaid
AR127031003Medicaid
D38536Medicare UPIN
5J625Medicare PIN
AR127031003Medicaid