Provider Demographics
NPI:1992170856
Name:GANSEN, GARY (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 KENYON RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5742
Mailing Address - Country:US
Mailing Address - Phone:515-574-6880
Mailing Address - Fax:
Practice Address - Street 1:804 KENYON RD
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5742
Practice Address - Country:US
Practice Address - Phone:515-574-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078754213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery