Provider Demographics
NPI:1730117003
Name:MARDER, GARY LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:MARDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9580 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4217
Mailing Address - Country:US
Mailing Address - Phone:772-335-1500
Mailing Address - Fax:772-335-1116
Practice Address - Street 1:9580 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4217
Practice Address - Country:US
Practice Address - Phone:772-335-1500
Practice Address - Fax:772-335-1116
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4773207KA0200X, 207KI0005X, 207ND0900X, 207NI0002X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82760OtherBCBS
FL82760BMedicare PIN