Provider Demographics
NPI:1598299141
Name:TACKLING, GARY JAMES (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JAMES
Last Name:TACKLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8100
Mailing Address - Fax:850-863-8548
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-485-3066
Practice Address - Fax:303-485-3060
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME145962207R00000X
CODR.0067063207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine