Provider Demographics
NPI:1508337676
Name:DORIS, GERARD THOMAS III
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:THOMAS
Last Name:DORIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 NOTTINGHAM CT APT 252
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4687
Mailing Address - Country:US
Mailing Address - Phone:813-365-2494
Mailing Address - Fax:
Practice Address - Street 1:3409 NOTTINGHAM CT APT 252
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-4687
Practice Address - Country:US
Practice Address - Phone:813-365-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-2319791Medicaid