Provider Demographics
NPI:1528061231
Name:MOORMAN, GARY L (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:MOORMAN
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 1:2942 SHORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-1248
Mailing Address - Country:US
Mailing Address - Phone:419-729-5785
Mailing Address - Fax:419-729-4028
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-4204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003175207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114808628Medicaid
P00280770OtherRAILROAD MEDICARE
000000377156OtherBCBS
OH000000360664OtherBCBS
MI114734293Medicaid
OH0510343Medicaid
OH0510343Medicaid
MO0498063Medicare PIN
OH000000360664OtherBCBS