Provider Demographics
NPI:1275519985
Name:SHANKS, GARY EDWARD (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:EDWARD
Last Name:SHANKS
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:810 W HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-8602
Practice Address - Country:US
Practice Address - Phone:830-201-8000
Practice Address - Fax:830-201-8008
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32799207L00000X
TXN0454207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0196691Medicaid
G75972Medicare UPIN
04722Medicare ID - Type Unspecified