Provider Demographics
NPI:1669558573
Name:GARRY, JOHN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:GARRY
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 1:6121 N THESTA
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:559-440-0283
Mailing Address - Fax:559-440-0192
Practice Address - Street 1:6121 N THESTA
Practice Address - Street 2:SUITE 202
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-440-0283
Practice Address - Fax:559-440-0192
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39995208C00000X
MI4301046027208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G399950Medicaid
CA00G399950Medicaid
CA00G399950Medicare ID - Type Unspecified