Provider Demographics
NPI:1962548552
Name:FRICK, GARY WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIAM
Last Name:FRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:790 DUNLAWTON AVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9279
Mailing Address - Country:US
Mailing Address - Phone:386-767-8584
Mailing Address - Fax:386-767-8536
Practice Address - Street 1:804 DUNLAWTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4931
Practice Address - Country:US
Practice Address - Phone:386-767-8584
Practice Address - Fax:386-767-8536
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME733162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252667100Medicaid
FL41940WMedicare PIN
FL252667100Medicaid