Provider Demographics
NPI:1295746857
Name:PRANT, GARY D (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:PRANT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7700 MENAUL BLVD NE STE D
Mailing Address - Street 2:
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 STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4639
Practice Address - Country:US
Practice Address - Phone:505-299-4487
Practice Address - Fax:505-299-4498
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPOD411213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92337287Medicaid
TX1079010001Medicare NSC
T15353Medicare UPIN