Provider Demographics
NPI:1942756440
Name:EMMERSON, GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:EMMERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N TUSTIN AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3612
Mailing Address - Country:US
Mailing Address - Phone:714-836-4553
Mailing Address - Fax:
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:STE 300
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-836-4553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14596Medicare PIN