Provider Demographics
NPI:1275634859
Name:SKINNER, GARY OWEN (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:OWEN
Last Name:SKINNER
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 1:18675 EAST 39TH STREET
Mailing Address - Street 2:SUITE M
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1762
Mailing Address - Country:US
Mailing Address - Phone:816-795-9911
Mailing Address - Fax:816-795-1911
Practice Address - Street 1:18675 EAST 39TH STREET
Practice Address - Street 2:SUITE M
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1762
Practice Address - Country:US
Practice Address - Phone:816-795-9911
Practice Address - Fax:816-795-1911
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5996208D00000X
HI692208D00000X
KS0516202208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice