Provider Demographics
NPI:1457560955
Name:INGRAM, GERARD JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:JOSEPH
Last Name:INGRAM
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 1:1678 RIVERDALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOPE ISLAND
Mailing Address - State:QUEENSLAND
Mailing Address - Zip Code:04212
Mailing Address - Country:AU
Mailing Address - Phone:6175-530-8403
Mailing Address - Fax:6175-530-1421
Practice Address - Street 1:1678 RIVERDALE DRIVE
Practice Address - Street 2:
Practice Address - City:HOPE ISLAND
Practice Address - State:QUEENSLAND
Practice Address - Zip Code:04212
Practice Address - Country:AU
Practice Address - Phone:6175-530-8403
Practice Address - Fax:6175-530-1421
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54947207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology