Provider Demographics
NPI:1689916223
Name:SKALETSKY, GARY STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:STEVEN
Last Name:SKALETSKY
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:P.O. BOX 778
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5429
Mailing Address - Country:US
Mailing Address - Phone:630-803-4711
Mailing Address - Fax:
Practice Address - Street 1:40 TERRY DR
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-5429
Practice Address - Country:US
Practice Address - Phone:630-803-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-54690-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist