Provider Demographics
NPI:1750305892
Name:MANTELL, GARY MARC (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARC
Last Name:MANTELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5180 PARK AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3530
Mailing Address - Country:US
Mailing Address - Phone:901-682-4668
Mailing Address - Fax:901-683-2963
Practice Address - Street 1:5180 PARK AVE STE 220
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3530
Practice Address - Country:US
Practice Address - Phone:901-682-4668
Practice Address - Fax:901-683-2963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM283213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351206Medicare ID - Type Unspecified
TNT61097Medicare UPIN