Provider Demographics
NPI:1588780373
Name:WILLARD, GARY MARVIN (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MARVIN
Last Name:WILLARD
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 1:2588F EL CAMINO REAL STE 127
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1201
Mailing Address - Country:US
Mailing Address - Phone:619-564-4644
Mailing Address - Fax:619-810-2430
Practice Address - Street 1:2588F EL CAMINO REAL STE 127
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1201
Practice Address - Country:US
Practice Address - Phone:619-564-4644
Practice Address - Fax:619-810-2430
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34995174400000X
NY254000207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03132152Medicaid
CAFE799ZOtherMEDICARE ID
CAFE799ZOtherMEDICARE ID
CA03132152Medicaid