Provider Demographics
NPI:1063432144
Name:VISNER, GARY A (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:VISNER
Suffix:
Gender:M
Credentials:DO
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Other - Last Name:
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Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:CHILDREN'S HOSPITAL BOSTON
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-1900
Mailing Address - Fax:617-730-0084
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL BOSTON
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6105
Practice Address - Fax:617-730-0084
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA233187208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0105431Medicaid
PA101504318Medicaid
NJ0105431Medicaid
PA099353Medicare ID - Type Unspecified