Provider Demographics
NPI:1710170568
Name:VISSER, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VISSER
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 1:2940 MAGUIRE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4751
Mailing Address - Country:US
Mailing Address - Phone:407-581-9065
Mailing Address - Fax:321-348-5827
Practice Address - Street 1:2940 MAGUIRE RD STE 200
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4751
Practice Address - Country:US
Practice Address - Phone:407-581-9065
Practice Address - Fax:321-348-5827
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105459207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO5086OtherHF MEDICARE