Provider Demographics
NPI:1598299273
Name:DESINORD, GARY
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:DESINORD
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:
Practice Address - Street 1:320 PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4538
Practice Address - Country:US
Practice Address - Phone:863-687-1466
Practice Address - Fax:863-687-1467
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4125213ES0103X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program