MEDICARE: DR. GARY LEE MARDER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207KA0200X	Allergy Physician	OS4773	FL
2	207KI0005X	Clinical & Laboratory Immunology (Allergy & Immunology) Physician	OS4773	FL
3	207ND0900X	Dermatopathology Physician	OS4773	FL
4	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	OS4773	FL
5	2085R0001X	Radiation Oncology Physician	OS4773	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	82760	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1730117003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LEE MARDER D.O.

Provider Business Mailing Address
First Line	:	9580 S FEDERAL HWY
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-4217
Country	:	US
Telephone Number	:	772-335-1500
Fax Number	:	772-335-1116

Provider Business Practice Location Address
First Line	:	9580 S FEDERAL HWY
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-4217
Country	:	US
Telephone Number	:	772-335-1500
Fax Number	:	772-335-1116

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	03/04/2008

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