Provider Demographics
NPI:1457333031
Name:PRESCOTT, GARY W (CO/LPO)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:PRESCOTT
Suffix:
Gender:M
Credentials:CO/LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6715 SAN PEDRO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7218
Mailing Address - Country:US
Mailing Address - Phone:210-224-0726
Mailing Address - Fax:210-341-3164
Practice Address - Street 1:6715 SAN PEDRO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7218
Practice Address - Country:US
Practice Address - Phone:210-224-0726
Practice Address - Fax:210-341-3164
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0000801744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0401610006Medicare ID - Type UnspecifiedAUSTIN MC#
TX0401610004Medicare ID - Type UnspecifiedNEW BRAUNF MC#
TX0401610001Medicare ID - Type UnspecifiedSAN ANTONIO MEDICARE #
TX0401610007Medicare ID - Type UnspecifiedMED CTR MC #
TX0401610002Medicare ID - Type UnspecifiedLAREDO MC #