Provider Demographics
NPI:1376572131
Name:GULISH, GARY BYRON (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BYRON
Last Name:GULISH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1548 FALCON CREST DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3587 12TH ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-9569
Practice Address - Country:US
Practice Address - Phone:269-792-2263
Practice Address - Fax:269-792-4344
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGG008590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE25909Medicare UPIN
MI0P44470Medicare PIN