Provider Demographics
NPI:1265464887
Name:FORNERA, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FORNERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD44135207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICARE GROUP
TN62-1081700OtherTAX ID #
TN3380640OtherMEDICAID GROUP
TN1513152Medicaid
TN62-1081700OtherTAX ID #