Provider Demographics
NPI:1952317323
Name:HEATH, GARY W (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:HEATH
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 9230
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9230
Mailing Address - Country:US
Mailing Address - Phone:800-633-1905
Mailing Address - Fax:913-491-0411
Practice Address - Street 1:625 EAST BROADWAY
Practice Address - Street 2:ST JOHNS MEDICAL CENTER DEPT OF RADIOLOGY
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:800-633-1905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6361A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
6361AOtherWY MEDICAL LICENSE
310489OtherWYOMING BLUE
310489OtherWYOMING BLUE
C69451Medicare UPIN
BH0438273OtherDEA