Provider Demographics
NPI:1932239894
Name:DOTSON, GARY WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WESLEY
Last Name:DOTSON
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 1:852 VALLEY CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5005
Mailing Address - Country:US
Mailing Address - Phone:208-354-4757
Mailing Address - Fax:
Practice Address - Street 1:852 VALLEY CENTRE DR
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5005
Practice Address - Country:US
Practice Address - Phone:208-354-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6529A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B07363Medicare UPIN