Provider Demographics
NPI:1902823925
Name:GOFORTH, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:GOFORTH
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 1:15000 SHELL POINT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1657
Mailing Address - Country:US
Mailing Address - Phone:239-433-7937
Mailing Address - Fax:
Practice Address - Street 1:13880 SHELL POINT PLAZA
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3504
Practice Address - Country:US
Practice Address - Phone:239-466-1111
Practice Address - Fax:239-454-2111
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131713207Q00000X
FLMFC1687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006438400Medicaid
SC1703D8Medicaid
SC5254Medicare PIN
FLGJ889ZMedicare UPIN
FL006438400Medicaid
SC1127Medicare PIN