Provider Demographics
NPI:1659324416
Name:MISAMORE, GARY W (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:MISAMORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:201 PENNSYLVANIA PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-2301
Mailing Address - Country:US
Mailing Address - Phone:317-817-1200
Mailing Address - Fax:317-208-1551
Practice Address - Street 1:201 PENNSYLVANIA PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2301
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:317-208-1551
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-03-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01028154A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100461060Medicaid
IN200013396OtherRR MEDICARE
IN0208260001Medicare NSC
IND95608Medicare UPIN
IN100461060Medicaid