Provider Demographics
NPI:1558672014
Name:THEOFILIS, GARY GEORGE (DO, MBA, DABAM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:GEORGE
Last Name:THEOFILIS
Suffix:
Gender:M
Credentials:DO, MBA, DABAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 BROADWATER TRL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9521
Mailing Address - Country:US
Mailing Address - Phone:412-477-4493
Mailing Address - Fax:
Practice Address - Street 1:6125 BROADWATER TRL
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9521
Practice Address - Country:US
Practice Address - Phone:412-477-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS01718207LA0401X, 208VP0014X
GA74400208VP0014X, 207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine