Provider Demographics
NPI:1134390073
Name:GARY D PRANT
Entity type:Organization
Organization Name:GARY D PRANT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-299-4487
Mailing Address - Street 1:7700 MENAUL BLVD NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4639
Mailing Address - Country:US
Mailing Address - Phone:505-299-4487
Mailing Address - Fax:505-299-4498
Practice Address - Street 1:7700 MENAUL BLVD NE
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-299-4487
Practice Address - Fax:505-299-4498
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARY D PRANT DPM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-19
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92337287Medicaid