Healthcare Provider Details

I. General information

NPI: 1437139409
Provider Name (Legal Business Name): GARY M DERESH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CONSOLIDATED MEDICAL PLAZA 209 201 GAUTIER BENITEZ
CAGUAS PR
00725
US

IV. Provider business mailing address

35 JUAN C BORDON STE 67 PMB 394
GUAYNABO PR
00969
US

V. Phone/Fax

Practice location:
  • Phone: 787-745-4695
  • Fax: 787-745-4695
Mailing address:
  • Phone: 787-505-9237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number57
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: