Provider Demographics
NPI:1043459001
Name:GARY, JOHN W (BA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:GARY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-5110
Mailing Address - Country:US
Mailing Address - Phone:901-672-7549
Mailing Address - Fax:
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1420
Practice Address - Fax:901-369-1433
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator