Provider Demographics
NPI:1598166472
Name:FERAUDO, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FERAUDO
Suffix:
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 1:323 S MARION AVE
Mailing Address - Street 2:KNOX AVE
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7065
Mailing Address - Country:US
Mailing Address - Phone:386-867-0000
Mailing Address - Fax:386-755-3625
Practice Address - Street 1:323 S MARION AVE
Practice Address - Street 2:KNOX AVE
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7065
Practice Address - Country:US
Practice Address - Phone:386-867-0000
Practice Address - Fax:386-755-3625
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA69439172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist