Provider Demographics
NPI:1356445852
Name:VANN, GARY W (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:VANN
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 1:5682 W BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-2640
Mailing Address - Country:US
Mailing Address - Phone:559-271-7062
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25116174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A251160Medicaid
CAA24286Medicare UPIN
CA00A251160Medicaid