Provider Demographics
NPI:1922064179
Name:PLATT, GARY WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WALLACE
Last Name:PLATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1429 COLLEGE AVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4057
Mailing Address - Country:US
Mailing Address - Phone:209-557-5995
Mailing Address - Fax:209-557-5998
Practice Address - Street 1:1429 COLLEGE AVE
Practice Address - Street 2:SUITE L
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4057
Practice Address - Country:US
Practice Address - Phone:209-557-5995
Practice Address - Fax:209-557-5998
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2011-04-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG407852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G407850Medicare ID - Type Unspecified
CAA48351Medicare UPIN