Provider Demographics
NPI:1821053315
Name:WARD, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:WARD
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 1:1500 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3318
Mailing Address - Country:US
Mailing Address - Phone:573-686-4151
Mailing Address - Fax:
Practice Address - Street 1:2725 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2346
Practice Address - Country:US
Practice Address - Phone:573-686-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO188274OtherBLUE CROSS BLUE SHIELD
MO502259203Medicaid
MO953831128Medicare ID - Type Unspecified
MO188274OtherBLUE CROSS BLUE SHIELD