Healthcare Provider Details

I. General information

NPI: 1720014897
Provider Name (Legal Business Name): JACK N. GAY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 2ND AVE SW
LARGO FL
33770-3120
US

IV. Provider business mailing address

1301 2ND AVE SW
LARGO FL
33770-3120
US

V. Phone/Fax

Practice location:
  • Phone: 727-935-0500
  • Fax: 727-935-0501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME58150
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberME58150
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME58150
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME58150
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME58150
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: