Provider Demographics
NPI:1861494197
Name:KERSTEN, GARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
Last Name:KERSTEN
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 1:9515 W CAMELBACK RD
Mailing Address - Street 2:STE 108
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-1355
Mailing Address - Country:US
Mailing Address - Phone:602-428-0068
Mailing Address - Fax:602-428-0069
Practice Address - Street 1:9515 W CAMELBACK RD
Practice Address - Street 2:STE 108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-1355
Practice Address - Country:US
Practice Address - Phone:602-428-0068
Practice Address - Fax:602-428-0069
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21176207V00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173873Medicaid
AZMD21176Medicare ID - Type Unspecified
AZ173873Medicaid