Provider Demographics
NPI:1336353978
Name:WERDER, GABRIEL MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:MARK
Last Name:WERDER
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 1:373 PEREGRINE DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4744
Mailing Address - Country:US
Mailing Address - Phone:248-703-3878
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-549-0677
Practice Address - Fax:321-722-2432
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV248552085R0202X, 2085R0204X
VA01012532022085R0202X, 2085R0204X
FLME1263112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9545845OtherAETNA HEALTHCARE
VA10106888OtherSENTARA HEALTH PLAN
VA10103500OtherSENTARA HEALTH PLAN
FL101327600Medicaid
FLLQ097OtherFL MEDICARE
VAP01152597OtherRAILROAD MEDICARE
VA10106888OtherSENTARA HEALTH PLAN
VA10106888OtherOPTIMA HEALTH PLAN
VA10103500OtherSENTARA HEALTH PLAN
NC176PVOtherBCBSNC
VA9545845OtherAETNA HEALTHCARE
VA1336353978Medicaid