Provider Demographics
NPI:1881678696
Name:BERUBE, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BERUBE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 E STATE ROAD 205 STE 210
Practice Address - Street 2:SUITE 210
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-8506
Practice Address - Country:US
Practice Address - Phone:260-248-9230
Practice Address - Fax:260-248-9249
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048413A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000111719OtherANTHEM
IN9360OtherPHYSICIANS HEALTH PLAN
IN000000570537OtherANTHEM
IN3937240002OtherMEDICARE DMEPOS
00001071373OtherUNITED HEALTHCARE
IN200210030Medicaid
IN080130068OtherRAILROAD MEDICARE
IN3937240025OtherMEDICARE DMEPOS
4410292OtherAETNA
4410292OtherAETNA
IN3937240002OtherMEDICARE DMEPOS
F54938Medicare UPIN
IN080130068OtherRAILROAD MEDICARE
IN9360OtherPHYSICIANS HEALTH PLAN