Healthcare Provider Details

I. General information

NPI: 1427410976
Provider Name (Legal Business Name): GARY ALLEN DO, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4521 N DAVIS HWY
PENSACOLA FL
32503-2770
US

IV. Provider business mailing address

1707 N MAIN ST
GAINESVILLE FL
32609-3650
US

V. Phone/Fax

Practice location:
  • Phone: 850-494-9002
  • Fax:
Mailing address:
  • Phone: 352-265-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS15595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: