Healthcare Provider Details

I. General information

NPI: 1295746857
Provider Name (Legal Business Name): GARY D PRANT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 MENAUL BLVD NE STE D
ALBUQUERQUE NM
87110-4639
US

IV. Provider business mailing address

7700 MENAUL BLVD NE STE D
ALBUQUERQUE NM
87110-4639
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4487
  • Fax: 505-299-4498
Mailing address:
  • Phone: 505-299-4487
  • Fax: 505-299-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD411
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: