Provider Demographics
NPI:1811131311
Name:IDELCHIK, GARY M (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:IDELCHIK
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 1:1230 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2704
Mailing Address - Country:US
Mailing Address - Phone:307-266-3174
Mailing Address - Fax:307-266-3177
Practice Address - Street 1:1230 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2704
Practice Address - Country:US
Practice Address - Phone:307-266-3174
Practice Address - Fax:307-266-3177
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133430207RI0011X
NY259398207RC0000X
WY13381A207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY157420500Medicaid
FL102451000Medicaid
NY03824182Medicaid