Healthcare Provider Details

I. General information

NPI: 1508822693
Provider Name (Legal Business Name): GARY W. PROCOP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE HOLTZ BLDING 2090
MIAMI FL
33136-1005
US

IV. Provider business mailing address

5671 NW 112TH AVE #101
DORAL FL
33178-4141
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5068
  • Fax:
Mailing address:
  • Phone: 305-477-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number2291515
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2291515
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: