Healthcare Provider Details

I. General information

NPI: 1699720144
Provider Name (Legal Business Name): GARY A MARCOTTE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 W 101ST AVE
DYER IN
46311
US

IV. Provider business mailing address

15900 W 101ST AVE MARCOTTE MEDICAL GROUP, SC
DYER IN
46311
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-6333
  • Fax: 219-365-8291
Mailing address:
  • Phone: 219-365-6333
  • Fax: 219-365-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02000603A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036057151
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: