Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | OS4773 | FL |
N | 207ND0900X | Dermatopathologist | OS4773 | FL |
NPI | 1730117003 |
---|---|
Provider Name | Dr. Gary Lee Marder |
First Address | Port Saint Lucie, FL 34952-4217 |
Second Address | Port Saint Lucie, FL 34952-4217 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 04/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
82760 | BCBS (01) | FL |