Provider Demographics
NPI:1699753152
Name:JONES, GARY R (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:JONES
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:PO BOX 673739
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3739
Mailing Address - Country:US
Mailing Address - Phone:313-299-6650
Mailing Address - Fax:313-299-6651
Practice Address - Street 1:30 TOWER CT STE F
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3322
Practice Address - Country:US
Practice Address - Phone:847-662-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054590207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.141586OtherIL MEDICAL LIC
MI5572153OtherAETNA
MIGJ054590OtherLICENSE
MI125081OtherPREF CHOICE/CARE CHOICE
E 49380Medicare UPIN
MI5572153OtherAETNA