Healthcare Provider Details

I. General information

NPI: 1457420424
Provider Name (Legal Business Name): GARY JOHN THOMAS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 45TH ST STE F
MUNSTER IN
46321-3960
US

IV. Provider business mailing address

1650 45TH ST STE F
MUNSTER IN
46321-3960
US

V. Phone/Fax

Practice location:
  • Phone: 219-923-1254
  • Fax: 708-894-7176
Mailing address:
  • Phone: 219-923-1254
  • Fax: 708-894-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000534A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: