Provider Demographics
NPI:1528133022
Name:GARY D SMALL DPM CORP
Entity type:Organization
Organization Name:GARY D SMALL DPM CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-444-7114
Mailing Address - Street 1:2645 SW 37 AVE
Mailing Address - Street 2:#101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133
Mailing Address - Country:US
Mailing Address - Phone:305-444-7114
Mailing Address - Fax:305-444-9587
Practice Address - Street 1:2645 SW 37 AVE
Practice Address - Street 2:#101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133
Practice Address - Country:US
Practice Address - Phone:305-444-7114
Practice Address - Fax:305-444-9587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2363213ES0103X
213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390143200Medicaid
FLDD8704OtherRAILROAD MEDICARE
FLDD8704OtherRAILROAD MEDICARE
FL4685990001Medicare NSC
FL390143200Medicaid