Provider Demographics
NPI:1659383503
Name:MEREDITH, GARY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N BROADWAY UNIT 698
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-5034
Mailing Address - Country:US
Mailing Address - Phone:516-650-4733
Mailing Address - Fax:
Practice Address - Street 1:425 N BROADWAY UNIT 698
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-5034
Practice Address - Country:US
Practice Address - Phone:516-650-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151225207RR0500X
WI1258207RR0500X
CT56383207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B19256Medicare UPIN
NY76D711Medicare PIN