Provider Demographics
NPI:1548453210
Name:MART, GERALD RICHARD
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RICHARD
Last Name:MART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 CONNOR AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-3636
Mailing Address - Country:US
Mailing Address - Phone:305-785-6255
Mailing Address - Fax:407-373-6957
Practice Address - Street 1:530 W LANCASTER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4927
Practice Address - Country:US
Practice Address - Phone:407-373-6956
Practice Address - Fax:407-373-6956
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM630296521860111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation