Provider Demographics
NPI:1699706143
Name:NANCE, GARY G (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:NANCE
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 1:3445 POPLAR AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4667
Mailing Address - Country:US
Mailing Address - Phone:901-458-2020
Mailing Address - Fax:
Practice Address - Street 1:3445 POPLAR AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4667
Practice Address - Country:US
Practice Address - Phone:901-458-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN705T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0784010001OtherDMERC REGION C PALMETTO GBA
TNT61177Medicare UPIN
TN0784010001OtherDMERC REGION C PALMETTO GBA