Provider Demographics
NPI:1245546167
Name:ROBINSON, GARY LEE (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:ROBINSON
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:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:5270 BABCOCK ST NE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-8630
Practice Address - Country:US
Practice Address - Phone:321-722-5959
Practice Address - Fax:321-722-5960
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002677700Medicaid
D93042Medicare UPIN