Provider Demographics
NPI:1306837281
Name:GANIBAN, GARY J (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:GANIBAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E NASA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1998
Mailing Address - Country:US
Mailing Address - Phone:321-999-7456
Mailing Address - Fax:
Practice Address - Street 1:175 E NASA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1998
Practice Address - Country:US
Practice Address - Phone:321-999-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0057603207W00000X
FLME0076850207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E1287ZMedicare ID - Type Unspecified
F86137Medicare UPIN
FLE1287ZMedicare PIN