Provider Demographics
NPI:1639380892
Name:DESPRES, GARY (PT)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:DESPRES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0931
Mailing Address - Country:US
Mailing Address - Phone:631-765-8760
Mailing Address - Fax:631-765-8761
Practice Address - Street 1:53345 ROUTE 25 BLDG 8-1
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4643
Practice Address - Country:US
Practice Address - Phone:631-765-8760
Practice Address - Fax:631-765-8761
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62 0283742251X0800X
NY028374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic