Healthcare Provider Details

I. General information

NPI: 1639406598
Provider Name (Legal Business Name): DANIEL ROBERT GERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 REYNOLDS ST
MONROE NC
28112-4351
US

IV. Provider business mailing address

1107 REYNOLDS ST
MONROE NC
28112-4351
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-7575
  • Fax: 704-752-7576
Mailing address:
  • Phone: 704-752-7575
  • Fax: 704-752-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2020-03139
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number006119
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: