Provider Demographics
NPI:1932173754
Name:BROTHERSON, GARY T (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:BROTHERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1801 WEST 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4938
Mailing Address - Country:US
Mailing Address - Phone:814-455-8004
Mailing Address - Fax:814-456-6054
Practice Address - Street 1:1801 WEST 8TH STREET
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4938
Practice Address - Country:US
Practice Address - Phone:814-455-8004
Practice Address - Fax:814-456-6054
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030604207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000973098001Medicaid
PA000973098001Medicaid
PA071676QWBMedicare ID - Type UnspecifiedINDIVUAL GROUP #
PAB34959Medicare UPIN