Provider Demographics
NPI:1154405207
Name:GARY, CRYSTAL B (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:B
Last Name:GARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:GAIL
Other - Last Name:BAILEY GARY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:123 WEAVER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3155
Mailing Address - Country:US
Mailing Address - Phone:706-745-9417
Mailing Address - Fax:706-439-6482
Practice Address - Street 1:123 WEAVER RD
Practice Address - Street 2:SUITE A
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3155
Practice Address - Country:US
Practice Address - Phone:706-745-9417
Practice Address - Fax:706-439-6482
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27865207Q00000X
GA058943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51368Medicare UPIN