Provider Demographics
NPI:1780634022
Name:FORD, GARY E (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:FORD
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 1:1045 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 575
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4128
Mailing Address - Country:US
Mailing Address - Phone:310-329-8633
Mailing Address - Fax:310-329-8636
Practice Address - Street 1:1045 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 575
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4128
Practice Address - Country:US
Practice Address - Phone:310-329-8633
Practice Address - Fax:310-329-8636
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36302207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G363020Medicaid
CAE49227Medicare UPIN