Provider Demographics
NPI:1124000237
Name:MIDLA, GARY S (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:MIDLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 HADLEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1794
Practice Address - Country:US
Practice Address - Phone:317-831-9340
Practice Address - Fax:317-834-5768
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000703A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100434160AMedicaid
IN100434160AMedicaid
IN182470BMedicare ID - Type Unspecified