Provider Demographics
NPI:1134155351
Name:KRESGE, GARY D (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:KRESGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 FULTON ST G
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2008
Mailing Address - Country:US
Mailing Address - Phone:419-732-8837
Mailing Address - Fax:419-734-6658
Practice Address - Street 1:611 FULTON ST G
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2008
Practice Address - Country:US
Practice Address - Phone:419-732-8837
Practice Address - Fax:419-734-6658
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-004197207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH200041541OtherMEDICARE RAILROAD
OH0655554Medicaid
OH0655554Medicaid
OH4258080004Medicare NSC
OHA16701Medicare UPIN