Provider Demographics
NPI:1629011812
Name:PEARSON, GARRY D (DO)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:D
Last Name:PEARSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2511 W EDGEWOOD DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5869
Mailing Address - Country:US
Mailing Address - Phone:573-761-2130
Mailing Address - Fax:573-761-6957
Practice Address - Street 1:2511 W EDGEWOOD DR
Practice Address - Street 2:SUITE F
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5869
Practice Address - Country:US
Practice Address - Phone:573-761-2130
Practice Address - Fax:573-761-6957
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246900401Medicaid
MO246900401Medicaid
MO002013179Medicare ID - Type UnspecifiedMEDICARE