Provider Demographics
NPI:1376342998
Name:GEORGE, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-3325
Mailing Address - Country:US
Mailing Address - Phone:402-658-6652
Mailing Address - Fax:
Practice Address - Street 1:7110 F ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68117-1014
Practice Address - Country:US
Practice Address - Phone:712-328-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH12145135172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver