Provider Demographics
NPI:1891862769
Name:GANO, DAVID L (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:GANO
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2517 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2409
Practice Address - Country:US
Practice Address - Phone:360-748-8632
Practice Address - Fax:360-807-7687
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048719207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1056090Medicaid
MT1891862769Medicaid
ID807850800Medicaid
OR244205Medicaid
WAG8868381Medicare PIN
WAG8868382Medicare PIN
WAG8868385Medicare PIN