Provider Demographics
NPI:1508899402
Name:MONTSDEOCA, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MONTSDEOCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:MONTSDEOCA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PA
Mailing Address - Street 1:4343 SUN N LAKE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2162
Mailing Address - Country:US
Mailing Address - Phone:863-382-9100
Mailing Address - Fax:863-382-8928
Practice Address - Street 1:4343 SUN N LAKE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2162
Practice Address - Country:US
Practice Address - Phone:863-382-9100
Practice Address - Fax:863-382-8928
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0024449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78525Medicare ID - Type Unspecified
FLD82551Medicare UPIN