Provider Demographics
NPI:1982697611
Name:THEALL, GARY W (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:THEALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-0350
Mailing Address - Country:US
Mailing Address - Phone:845-986-4949
Mailing Address - Fax:845-986-9388
Practice Address - Street 1:55 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-4105
Practice Address - Country:US
Practice Address - Phone:845-986-4949
Practice Address - Fax:845-986-9388
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1817741208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01184569Medicaid
NY01184569Medicaid
NYE44927Medicare UPIN