Healthcare Provider Details

I. General information

NPI: 1750487872
Provider Name (Legal Business Name): GAINESVILLE UROLOGY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 NW 8TH AVE SUITE 2
GAINESVILLE FL
32605-4582
US

IV. Provider business mailing address

4881 NW 8TH AVE SUITE 2
GAINESVILLE FL
32605-4582
US

V. Phone/Fax

Practice location:
  • Phone: 352-373-6338
  • Fax: 352-373-6144
Mailing address:
  • Phone: 352-373-6338
  • Fax: 352-373-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0048155
License Number StateFL

VIII. Authorized Official

Name: DR. CLARK DALE GADDY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 352-373-6338