Provider Demographics
NPI:1437139409
Name:DERESH, GARY M (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:DERESH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 JUAN C BORDON STE 67
Mailing Address - Street 2:PMB 394
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-505-9237
Mailing Address - Fax:
Practice Address - Street 1:CONSOLIDATED MEDICAL PLAZA 209
Practice Address - Street 2:201 GAUTIER BENITEZ
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-745-4695
Practice Address - Fax:787-745-4695
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR57213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRU52972Medicare UPIN