Provider Demographics
NPI:1386675080
Name:FOSTER, GARY L (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:FOSTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E MAIN ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-366-3025
Mailing Address - Fax:631-366-3026
Practice Address - Street 1:222 E MAIN ST
Practice Address - Street 2:SUITE 340
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-366-3025
Practice Address - Fax:631-366-3026
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0162251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ39061Medicare PIN