Provider Demographics
NPI:1871657262
Name:MACON, GARY RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RAY
Last Name:MACON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5710 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5705
Mailing Address - Country:US
Mailing Address - Phone:586-264-3011
Mailing Address - Fax:586-264-5334
Practice Address - Street 1:5710 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5705
Practice Address - Country:US
Practice Address - Phone:586-264-3011
Practice Address - Fax:586-264-5334
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU59112Medicare UPIN