Provider Demographics
NPI:1548795651
Name:PEARSON, GARRY JR
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:
Last Name:PEARSON
Suffix:JR
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 1:2121 ORANGE BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-4963
Mailing Address - Country:US
Mailing Address - Phone:317-989-1078
Mailing Address - Fax:
Practice Address - Street 1:2121 ORANGE BLOSSOM CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-4963
Practice Address - Country:US
Practice Address - Phone:317-989-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38267744172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver