Provider Demographics
NPI:1508835885
Name:WERTMAN, GARY VAN (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:VAN
Last Name:WERTMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:ORBISONIA
Mailing Address - State:PA
Mailing Address - Zip Code:17243
Mailing Address - Country:US
Mailing Address - Phone:814-447-5556
Mailing Address - Fax:814-447-5682
Practice Address - Street 1:626 WATER STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:ORBISONIA
Practice Address - State:PA
Practice Address - Zip Code:17243
Practice Address - Country:US
Practice Address - Phone:814-447-5556
Practice Address - Fax:814-447-5682
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADOOS005169L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008434780002Medicaid
393824Medicare ID - Type Unspecified
B36725Medicare UPIN